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First published 2010 Finesse Press PO Box 1158 Byron Bay, NSW 2481 National Library of Australia Cataloguing-in-Publication

data Wilde, Sally, 1949 The History of Surgery Trust, Patient Autonomy, Medical Dominance and Australian Surgery, 18901940 ISBN 978-0980700824 Finesse Press 2010 This book is subject to copyright and copyleft. You have permission to post this PDF online, email it, print it and pass it along for free to anyone you like, as long as you make no changes or edits to its contents or digital format. In fact, Id love it if youd make lots and lots of copies. The right to bind this and sell it as a book, however, is strictly reserved. Enquiries should be made to the Manager, Finesse Press, PO Box 1158, Byron Bay NSW 2481 Copying for educational purposes The Australian Copyright Act 1968 (Act) allows a maximum of one chapter or 10 per cent of this book, whichever is the greater, to be copied by an educational institution for educational purposes provided that the educational institution (or the body that administers it) has given a renumeration notice to Copyright Agency Limited (CAL) under the Act. Details of the CAL licence for educational institutions are available from CAL, 15/233 Castlereagh Street, Sydney, NSW 2000, telephone: 1800 066 844, facsimile: (02) 9394 7601, e-mail: info@copyright.com.au The information contained in this book is to the best of the authors and publishers knowledge true and correct. Every effort has been made to ensure its accuracy, but the author and publisher do not accept responsibility for any loss, injury or damage arising from such information. Cover and text design: moonsaildesign.com.au

The History of Surgery


Trust, Patient Autonomy, Medical Dominance and Australian Surgery, 18901940

Sally Wilde

finesse press

Contents

Introduction: Doctors, Patients and Trust Part 1: Patients 1: Patients and the changing roads to surgery 2: From buyer beware to doctor knows best 3: Going under the knife Intermezzo 4: The operations Part 2: Surgeons 5: Achieving distinction 6: In theatre 7: The Royal Australasian College of Surgeons

Acknowledgements
I would like to begin by gratefully acknowledging the support of the Australian Research Council, which funded the research on which this book is based. I would also like to thank my colleagues at the University of Queensland, especially Sarah Ferber and all the other Moggies (dont ask; they know who they are!). Their insightful ideas during numerous Moggy seminars contributed enormously to the development of the ideas which follow. I would also like to thank the many archivists in Melbourne, Brisbane and London who were unfailingly skilled and cheerful in tracking down exactly what I was looking for. Particular thanks are due to Colin Smith and Katherine Green at the Royal Australasian College of Surgeons in Melbourne, Gabriele Haveaux at the Royal Melbourne Hospital Archives and Annie Lindsay at the University College Hospital, London, Archives. I would also like to thank Dominique Falla and all the other clever people at Moonsail Design and Finesse Press, and finally, but most importantly, Geof Hirst, for regular surgical reality checks and ongoing intellectual support.

Sally Wilde, Brisbane, June 2010

Introduction: Doctors, Patients and Trust


There are a number of scholarly histories of surgery that detail who invented what when, but this is not that sort of history.1 Instead, this book asks why we trust surgeons, or rather, it asks how we have come to trust surgeons, because such trust has not always been there. Allowing strangers to work on our unconscious bodies with knives requires an enormous leap of faith. Why do we believe that surgeons will act in the best interests of our health, rather than in the best interests of their wallets? In the late nineteenth century, people tended to take a fairly sceptical approach to medical practitioners. As George Bernard Shaw wrote in 1909: That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.2 In the 1890s, surgery still had many of the characteristics of a commodity, and patients and their friends made up their own minds whether and when and from whom they were going to buy it. This was in stark contrast to the public perception of surgeons that came to predominate half a century later, by which time surgeons were widely regarded as gentlemanly experts, above the sordid business of making money. In the period covered by this book, general public attitudes to medical practitioners were transformed from buyer beware to doctor knows best. This period was also one of fundamental change in Australian medicine as a whole. At the end of the nineteenth century, the acceptance of germ theory enabled doctors trained in western medicine to offer effective advice on the prevention of infectious disease. Germ theory was built around the idea that specific organisms caused specific diseases, as opposed to the older ideas that miasmas, or bad air, were responsible for everything from malaria to infected wounds. Half a century later, following the development of the sulphonamides and penicillin, it became possible to offer cures to some of those infections.3 Neither of those revolutions in medicine was as clear-cut in practice as the science behind them was in theory. People still caught, and died of, typhoid for decades after its causes were understood and preventative measures were possible. In contrast, mortality rates from infant diarrhoea fell dramatically long before any scientific consensus was reached on preventative measures. Sulphonamides, the first of the antibiotics, were prescribed inappropriately in the 1930s and manufactured unsafely, while public expectations of their ability to cure outran their actual therapeutic effectiveness. Life (and death) is a great deal messier and more complicated than scientific experiments, and both are shaped by the social and political contexts in which they occur.4

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Sally Wilde, The History of Surgery

The focus in this volume, however, is not on the development of more effective medications, but on the circumstances surrounding the development of more effective surgery, and the shifting conditions under which patients came to agree with doctors that surgery could help them.5 As with medicine as a whole, there was no neat one-to-one correspondence between developments in the science behind surgery and cured patients. What worked in theory might not work in practice, while patients sometimes surprised surgeons by getting better despite, rather than because of, what they did. As one Australian surgeon put it in 1938, discussing the work of an American colleague: He has had the same experience as we have, vis. some of the [operations] he has been most pleased with have been followed by the worlds worst results while others that looked like the dogs dinner have turned out 100%.6 Equally, there was no tidy co-incidence in timing between the ability of surgeons to make people better, and public confidence in surgery. In the late nineteenth century, surgeons worked within a framework of changing ideas on disease causation that constituted what Thomas Kuhn has described as a paradigm shift.7 Following a string of discoveries linking specific organisms to specific diseases, especially by Louis Pasteur and his colleagues in France, and Robert Koch and his colleagues in Germany, plus increasing publicity surrounding the work of British surgeon, Joseph Lister, doctors began to accept the germ theory of disease.8 Once a specific causative link had been established between a particular disease and a particular organism (for instance typhoid and Salmonella typhi in 1880, cholera and Vibrio cholerae in 1883, plague and Pasteurella pestis, now Yersinia pestis, in 1894), the laboratory offered not just an aid to the diagnosis of that disease, but effectively a new kind of definition of the disease, which was of practical significance to both doctors and patients.9 The result was an enormously optimistic medical atmosphere that reflected revolutionary changes in diagnosis, and powerful intellectual tools enhancing the ability to prevent, but not yet cure, many sorts of infectious disease. As Thomas McKeown famously pointed out, in the 1890s doctors did not yet have many effective therapies at their disposal that could have a major impact on mortality, but the new ways of understanding infectious disease were associated with an optimism, from the general public as well as doctors, that prevention, and even cure, was almost within their grasp.10 This view was confirmed in the first decade of the twentieth century, when German scientists successively identified the organism responsible for syphilis (Spirochaeta pallida, later called Treponema pallidum), devised a means of testing for its presence (the Wassermann test) and then systematically searched for and found a chemical, dihydroxy diamino arsenobenzene dihydrochloride or Salvarsan, which killed at least some Treponema pallidum some of the time.11 The era of effective chemo-therapy for disease had begun. Meanwhile, the authority of doctors, which had once rested principally on their class background, was coming to rest just as much on their expert knowledge.12 By and large, however, in the 1890s surgical confidence in what could be achieved had a distinct tendency to outrun surgical abilities. This did not apply to all surgeons, but it applied to a significant number, including many of those who gained the greatest reputations and advanced surgery the most. It was almost as if this confidence pulled surgery along behind it. But not all surgeons were the same, and for every confident risk-taker who advised an

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operation he had never previously performed, there was a slow, careful surgeon who advised watching and waiting. Patients varied, too, and while some were prepared to put their trust in the confident personalities, others preferred to trust in what seemed to them to be cautious advice. There were a number of what can perhaps be described as brash showmen among surgeons of this era, and although they were generally subject to disapproval from their colleagues, several of them made large fortunes selling surgery. In the late nineteenth century, increasing numbers of doctors adopted a professional rather than a businesslike style in how they made a living, but despite this, the public tended to remain sceptical. Many would have agreed with George Bernard Shaw that there was the ever-present potential for conflict between the doctors need for money and the patients best interests. This picture changed significantly, however, in the middle decades of the twentieth century, when medicine entered what has variously been called the era of medical dominance or the golden age of doctoring.13 The rise of the profession of medicine was associated with an anti-commercial ethic, and by the 1920s codes of medical ethics that forbade advertising and encouraged the treatment of the poor for free were firmly established and regarded as intimately linked with trust: There is only one admissible method of advertisement open to a medical practitionerthe performance of good work, [wrote the editor of the Medical Journal of Australia in 1921.] The patient trusts the doctor with confidences of a most intimate nature he trusts him with his life and he trusts him with what is almost a blank cheque. In these circumstances the medical profession has from time immemorial required its members to obey certain ethical rules, so that implicit trust may not be misplaced and so that the honour of the profession may be maintained.14 By the inter-war years, medical care had come to be widely regarded as something rather more important than a commodity to be bought and sold. In the United States in particular, this has long been recognised as very much to the advantage of doctors, where their increasing professional autonomy was accompanied by protected markets for their services, and the associated growth of the medical-industrial complex.15 In Australia (and New Zealand and Britain), however, the emphasis was subtly different, and over time many factors combined to produce both greater government intervention in health and a stronger bias against overt markets for health care. This difference is well illustrated by the mid-twentieth century conceptualisation of blood as a commodity in the United States, with paid suppliers, while blood was donated as a gift in Britain, Australia and New Zealand.16 By the interwar years, like many other aspects of medical care, surgery in Australia had shifted its centre of gravity definitively out of the market place and into the realm of the moral economy.17 Health care was in the process of becoming something that ought to be delivered on the basis of need, rather than on the basis of ability to pay, a viewpoint that was already implicit in the words of George Bernard Shaw quoted above. Although state-funded medical care is associated particularly with the period after World

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War II, in both Australia and Britain the long and complex process of increasing government subsidy for allopathic medicine was well under way by 1940.18 Surgery (once diagnosed by a doctor as advisable) had come to be considered as essential rather than optional, something that people needed, whether they were rich or poor. This attitude was associated with a benevolent image of surgeons throughout the middle decades of the twentieth century. A reverent aura enveloped the cutting and stitching of unconscious bodies under bright lights, and those who put on special costumes and performed marvels on those medical stages had taken several steps up a pedestal above the mere mortals that they treated. Throughout the book, three themes crop up repeatedly as the reasons for this changing image of surgery are examined: the relationship between surgery and science, the relationship between surgery and society and the significance of the cult of the surgeon as hero.

Science and surgery


In the closing decades of the nineteenth century, laboratory-based medical research was all the rage, especially in Germany and France.19 There were laboratories for physiological experiments on live animals, for instance, and for the pathological examination of tissue under a microscope. Private companies, government-sponsored research institutes and scientists funded by philanthropic donations were all working on a range of projects, including the production of synthetic versions of natural drugs such as salicylic acid (available over the counter as aspirin in powder form from 1899), the identification of bacteria and the production of vaccines.20 By 1900, none of these kinds of laboratories had produced very much that directly cured disease, but they had collectively transformed the way that not only doctors, but also many members of the public, understood the causes of ill health. As has already been noted, in the late nineteenth century, the work of Louis Pasteur in France and Robert Koch in Germany, as well as many others, resulted in a mounting body of evidence that at least some diseases were caused by specific organisms. But acceptance of this germ theory was a complex process, with some people very much more ready than others to adopt the latest ideas. What seemed obvious by 1900 to most of those interested in science and medicinethat diphtheria could not arise without the presence of the Klebs-Lffler bacillus [now Corynebacterium diphtheriae], for instance, or that tuberculosis was directly caused by Mycobacterium tuberculosiswas not at all obvious, even within the scientific community, in 1880. This was the context in which surgery rose to prominence as a method of treatment. Most explanations for the rise in surgery in the late nineteenth century emphasise the importance of the twin developments of various methods of anaesthesia from the 1840s, and increasingly effective methods to prevent post-operative infection from the 1880s.21 Since the work of Owsei Temkin in the 1950s, historians have also emphasised the importance of the surgical point of view, the idea that the body was amenable to repair by tinkering around with its internal workings, first by cutting out parts and subsequently attempting to restore normal function by reconstruction and even transplantation.22 By the early twentieth century,

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Lord Lister in particular had come to be credited by his many admirers with almost singlehandedly giving birth to modern surgery through his development of antiseptic operating techniques, with the objective of killing harmful organisms in and around the wound. These techniques included the copious use of antiseptic substances such as carbolic, whether in wound dressings or sprayed into the air during surgery. The slow and uneven acceptance of germ theory has been particularly well documented in the case of ideas about the causation of wound infection.23 Recent assessments of Listers contribution have pointed out that his own understanding of the causes of infection changed over time, as did his methods, and that other surgeons were getting improved results at the same time using different approaches.24 But by 1890, virtually all surgeons had adopted some version of antiseptic or the newer aseptic operating technique (which aimed to keep harmful organisms from coming into contact with the surgical field, rather than trying to kill them once they were there), and there are many indications that they now believed this could prevent wound infection. By the turn of the century, when wounds did become infected, the response from doctors was no longer to question germ theory, but rather to question the details of their technique. Either they, or a nurse, or even the patient had been responsible for some lapse in the appropriate behaviour needed to prevent bacteria from multiplying in the body. However, it was not this belief alone that triggered the enormous increase in the number and range of surgical procedures performed. For those of us who grew up believing that doctors generally have the welfare of their patients at heart, it may be difficult to conceptualise surgery as a commercial transaction. But in the late nineteenth century there were fewer third party payers in the business of medical care. There were friendly society clubs and there were charitable hospitals and dispensaries, but most surgeons were paid, most of the time, directly by their patients, or their patients parents, or their patients spouses. In the absence of major health insurance companies or government-funded health care, patients had a very much more direct appreciation of the costs of medical treatment. Consequently, quite apart from overcoming their fear of pain and death, patients had to be convinced that the costs of surgery would be worthwhile. Nineteenth-century surgeons could not take it for granted that their patients would consent to any proposed operation and, on the contrary, patients often refused to submit to surgery. They had to be persuaded that surgery was in their best interests.25

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Society and surgery


As has already been noted, one of the most interesting features of this period is that people began to have confidence in the therapeutic efficacy of scientific medicine well in advance of any credible evidence that this confidence was justified. During the 1920s and 1930s, the Labor Party in the State of Queensland, for instance, set about providing free infant welfare centres, maternity wards and public hospitals, funded by a lottery.26 In Britain, Lloyd George had earlier taken an insurance-based approach, but never-the-less legislated to provide what became the basis of widespread working class access to doctors. Political parties representing working-class interests clearly believed that their constituents were at a disadvantage if

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they could not afford orthodox medical care. With fertility rates falling in a pro-natalist atmosphere, they also turned to orthodox medical advice to help (further) reduce infant and maternal mortality.27 In the period 18901940, individual life chances and the experience of sickness were inextricably entangled in social and geographic circumstances. Whether an individual had access to regular food, let alone medical and nursing care, and what sort of alternatives were available if they did not, made a difference to the way that people dealt with illness. There has been a marked tendency to study the history of individual health care and the history of public health as two completely separate topics, the first about what doctors did in treating individuals, and the second about what doctors and others did in trying to prevent disease on a broader scale. But from the point of view of the individual, their health or sickness was linked to both, to the range of bacteria in their food and drink, as well as to the vagaries of the infant diarrhoea treatment, for instance, favoured by their chosen doctor. Indeed, the currently accepted story is that public health measures may well have made a significant contribution to the falling death rates of the late nineteenth century, while the attempts by doctors to cure disease almost certainly had no significant impact on overall mortality before about the 1930s.28 Medical treatments did, however, have a very significant impact on the experience of sickness for those who chose to submit to them. Undergoing surgery may or may not have contributed to a longer life, but it was certainly a high impact mode of treatment compared to swallowing medicine or ignoring the pain in the hope that it would go away. Looking at history in the long run, a major change in human experience was more or less encompassed in the period 18901940. Child and infant mortality rates fell, and women stopped having so many children.29 In 1901, for instance, the Australian infant mortality rate was 97 deaths per 1000 live births, but this figure halved by 1930 and halved again by 1950.30 This meant that the grief of infant deaths, for both parents and siblings, had become less common, while falling fertility rates meant that many more children were growing up in smaller families and most women no longer spent a large proportion of their adult lives pregnant.31 Over the same period, death rates also fell at all ages, and life expectancy rose. Why, exactly, is still a matter for considerable debate, and the relative importance of rising living standards and public health provision remain contentious, but the broad outlines of the demographic transition are not in dispute, and the health implications of the change can hardly be overstated. Whether or not doctors contributed to falling death rates in the early part of this period, the potential efficacy of medical treatments had increased dramatically by the middle years of the twentieth century. At the same time, public faith in the ability of doctors to prevent and cure disease also rose rapidly. By the outbreak of World War II, women and men and children of all social classes were consulting doctors for all manner of problems, and increasingly often, doctors could actually help. Throughout this book it is argued that the trust or confidence that patients have in those they go to for medical advice, and the relationships that are established, are situated, not constant. Patients encounters with medical professionals vary enormously depending

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on the surrounding circumstances, including their age, gender, ethnicity, education and social background.32 Not all doctor-patient relationships are the same, and in practice they seldom involved a single doctor and a single patient. In private practice, patients typically encountered doctors in their own homes, while accompanied by friends or relations. In hospital, in contrast, solitary patients faced a multiplicity of nurses and doctors. In the 1890s, surgery was already moving from homes to hospitals, shifting the clinical encounter from the patients to the doctors territory, and the balance of power from the patient to the doctor. The idea of one doctor interacting with one patient is a convenient fiction that ignores the financial and administrative arrangements surrounding the relationship. This important point is discussed at greater length in Chapters 1 and 2.

The surgeon as hero


During the period 18901940 there was a radical change in the circumstances within which surgery was performed. Before about the 1920s, patients and their friends and families played an important role in decision-making about surgery. After World War I, in contrast, patients faded into the background of the decision-making process. This change in the autonomy enjoyed by patients is associated with the shift from performing most surgery in private homes to performing most surgery in hospital. In private practice, and especially in general practice, doctors could not ignore the wishes of patients and their friends and families. Operations had to be explained to themin effect sold to them. Patients had to be convinced to consent. In contrast, specialist surgeons in hospital practice depended on referrals from their colleagues, rather than direct approaches from patients. Colleague approval, therefore, came to matter more, and the cult of the individual surgeon as hero arose within this context of specialisation. Surgeons were people who had the courage and skill to do things that other doctors could not or would not do, but there was a further key component to the development of this image, and that was trust. Surgeons came to be trusted, not only for their ability/skill in solving medical problems and making patients better, but also for their benevolent intent. They came to be trusted to act in the best interests of their patients even (or perhaps especially) when those conflicted with the surgeons own financial interests. The technologies of operating theatres, beds, nursing and new operations were assembled in hospitals which were effectively workshops where patients bodies were the raw material and the finished products, but where the patients themselves and their views had become almost incidental to the process.33 However, outside of the workshops of surgery, patient opinions continued to matter; so did the views of the press, the public and governments. Surgeons devised ways to sell themselves to those groups, to convince them that it was safe to leave decisions about surgery to them and to convince the public that once people went into hospital, they were in safe hands. They persuaded the public to black box surgery and to leave worrying about what went on inside the black box to surgeons. They did this in a number of ways which are discussed at some length in Part 2, including by persuading the rest of the world to suspend the adage buyer beware when they thought they needed surgery, by selling surgical heroes, and by inventing tradition and emphasising the image of the expert, trustworthy gentleman, above the grubby pursuit of money.

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Sally Wilde, The History of Surgery

The trend to perform surgery in hospitals rather than private homes was therefore accompanied by a shift in the balance of power from the patient to the doctor. This in turn was followed by an acceptance of the way that doctors chose to represent the business of medicine, and they chose to represent it as not a business at all. In the 1930s, elite Australian and New Zealand surgeons consciously invented a tradition of dignified ceremonial, and emphasised an anticommercial ethic. Together, these innovations helped foster public confidence in surgery. The pattern of surgical practice developed in Australia and New Zealand had strong links to a similar pattern of referral-based surgical practice and honorary public hospital appointments developed in Britain, but contrasts with the greater emphasis on private practice in the United States, and direct access by patients to specialists.

Viewpoints in the surgical landscape


This book sets out to chart the transformation in the image of surgeons and surgery by examining the viewpoint of patients as well as the viewpoint of doctors. The first chapter draws on material from diaries and inquests and discusses some of the ways in which patients might end up unconscious on an operating table; the second uses the changing language in published medical case reports to examine the important late nineteenth-century changes in the power relationships between patients, their families, and health professionals; and the third examines patient records and hospital procedures to reconstruct the experience of undergoing surgery from the patients point of view. The viewpoint of doctors has been studied at some considerable length, but we know very much less about the agendas of patients, although they no longer, as F. B. Smith so wittily put it in 1979, loom small in medical history.34 Since the 1970s, there has been a considerable volume of scholarship on patient perspectives, which has served to emphasise the importance of religious denomination, as well as social class, in influencing the ways that people dealt with ill health.35 Much of this work has focussed on the point at which doctor and patient meet, the clinical encounter, but this can lead to a very partial glimpse of patient agendas. Although doctors spent their lives treating patients, very few patients spent their lives seeing doctors. While the doctors perspective on surgery invites attention to a series of operations, a flow of patients past the medical gaze and under the surgical knife, the patients perspective invites attention to a longer span of time, to the events which preceded and the events which followed surgery, as well as to the unconscious moments whilst submitting to surgical interference. In Chapter 4, the focus shifts to the operations themselves and outlines some characteristics of the enormous increase in the range of surgical operations and the frequency with which they were performed. Using hospital records, surgical text books from the 1890s to the 1930s, and debates in contemporary medical journals, this chapter briefly examines the procedures which became particularly popular in the early years of the twentieth century, as well as operations which fell out of fashion. Chapter 4 also includes a discussion of the processes involved in inventing new operations, and draws an important distinction between well-established surgical procedures, whose performance had become routine, and new operations where there was not yet any consensus as to whether, when and how they should be performed.

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The next three chapters shift the focus of attention from the patient to the surgeon, and attempt to glimpse surgeons in the round, so to speak, not just as disembodied intellects. Chapter 5 uses biographical material for a prosopographical study of the ways in which some doctors rose to prominence as elite specialists, and sets their surgical careers within the context of their home lives and their social lives. This was the culture within which an extraordinary ferment of technological and scientific innovation took place in the early twentieth century. Chapter 6 uses material from surgical diaries to examine what went on in operating theatres from the surgeons point of view. Chapter 7 uses material from the Archives of the Royal Australasian College of Surgeons to examine the related questions of how elite surgeons attempted to both improve surgical standards and set up methods of selfregulation in surgery. All three chapters emphasise the key role played by the moral economy of medicine as they set out to explain why so many people were prepared to trust surgeons so much.

Centres and peripheries and Australasian surgery


This is a history of Australian surgery, but it is impossible to write a history of Australian surgery without also making reference to New Zealand. Doctors in both countries tended to act as a group in the early twentieth century and set up many Australasia-wide organizations. In particular, when antipodean surgeons decided to band together to form a college, they took it for granted that it would cover both countries, and the formal foundation of what later became the Royal Australasian College of Surgeons took place in Dunedin (although the organization was effectively dominated by Melbourne surgeons for the next quarter of a century). Australian and New Zealand surgeons, therefore, acted as something of a block. Surgeons from both countries, however, were largely ignored, and occasionally patronised, by surgeons from Britain or North America.36 But what was peripheral from the perspective of London or Baltimore was central from the perspective of Auckland or Melbourne.37 Local surgeons had their own careers to build and their own stages on which to perform. They might aspire to knighthoods and their wives might aspire to be presented at court in London, but meanwhile, their consulting appointments to major public hospitals made them magnets for referrals from country general-practitioner surgeons. The major cities of Australasiathe capital cities of the Australian states, plus Dunedin, Christchurch, Auckland and Wellington in New Zealandwere all centres in their own right, with their own rural peripheries. The rivalry between Melbourne and Sydney for supremacy among Australian cities was played out in medicine, as in so many other fields of Australian life. Meanwhile, if publications in the Australasian medical journals are anything to go by, surgeons from Ballarat or Newcastle (and even, sometimes, from Adelaide and Brisbane) struggled to be taken seriously in either Sydney or Melbourne; surgeons from Auckland or Dunedin were likely to get a better hearing than those from Hobart, and surgeons in Perth did not even try. They sent their academic papers directly to the English journals. This hierarchy of place has been reflected in the historiography of Australian medicine. Despite the work of John Pearn and others in documenting the history of outback medicine,

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Sally Wilde, The History of Surgery

most major studies have had their intellectual centre of gravity in Sydney or Melbourne.38 This volume sets out to break with that pattern, and most of the major case studies have been drawn from both rural and urban areas of Victoria and Queensland. There are, however, multiple references to the changing surgical landscape in the other Australian States and New Zealand. In the nineteenth century, the vast majority of Australian and New Zealand doctors did at least some of their training in Britain and held British qualifications.39 By World War II, the medical schools in Adelaide, Dunedin, Melbourne and Sydney had largely replaced British institutions as places to receive basic medical training, and the new medical school in Brisbane was also beginning to train doctors, but British postgraduate qualifications continued to dominate. In particular, the Fellowships of the Royal Colleges of Surgeons of England and Edinburgh and, to a lesser extent, Ireland, remained the benchmark surgical qualifications in Australasia until at least the 1950s.40 However, Australian and New Zealand surgeons were also influenced by developments in North America. Round the world study tours taking in operating theatres in both Britain and North America were not uncommon by the 1920s, and although North American surgeons paid very little attention to Australasia, the reverse was not the case. By World War II, the average surgeon in Australia or New Zealand was likely to be just as well informed about developments in his or her specialty in Baltimore or Rochester as about developments in London or Liverpool.

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Part 1: Patients
What sort of circumstances might lead someone to agree to surgery? What was it like to go under the knife fifty or one hundred years ago? Why might people choose to have their surgery performed in their own home rather than in hospital and why did this change over the years? These are among the many questions addressed in these three chapters, as surgery is placed in the context of patients lives.

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Sally Wilde, The History of Surgery

Chapter 1: Patients and the Changing Roads to Surgery


In the late nineteenth and early twentieth centuries there was an extraordinary increase in the number and range of surgical procedures that were being performed. At the Royal Prince Alfred Hospital in Sydney, for instance, the number of operations increased from 147 in 1883 to more than 10,000 per year in the 1930s.41 Most attempts to explain this phenomenon have concentrated on the surgical point of view and looked for reasons why more surgeons were prepared to perform more operations more often. But there is another side to this story. The increasing number of operations depended upon increasing numbers of people prepared to submit to them. No-one is at very great risk of undergoing surgery unless they consult a doctor, and so this first chapter examines some of the paths that led patients to seek medical advice. The sources include the diaries and letters of ordinary Australian men and women, as well as some of the wealth of material which has survived from Queensland inquests.42 The examples that follow are not limited to the sorts of problems that might be considered surgical. Rather, they have been chosen because they illuminate some of the ways in which people might behave when they faced life-threatening conditions. Broadly speaking, it becomes clear that in the late nineteenth and early twentieth centuries, many people hardly ever consulted a doctor for anything at all.

In the 1890s, many babies failed to survive their first year or so, and people were only too well aware that young life was fragile. So when a baby became sick, this was hardly to be taken lightly. The following example from right at the beginning of the period under consideration offers something of a base line for how at least some mothers and fathers might have used the various options for the medical treatment of a sick infant in the 1890s. Little Billy began to suffer symptoms of infant diarrhoea and failure to thrive at one of the classic times of peak danger in his life: when he was weaned from his mothers milk.43 His mother, Mrs Clifton, kept a diary of her life and work on a small family farm north of Brisbane.44 In October 1887 she wrote: Billy is getting another tooth. Monday 10th I starting to wean Billy in the day time Throughout the next few weeks, his appetite was not good, and he began to lose weight. On 6th November, Mr Clifton went to see a neighbour to see if she had any chlorodyne, a popular remedy for teething babies.45 The composition of this and other popular remedies changed as the century progressed, and as drug regulation became stricter, the opium or morphine content tended to fall and the alcohol content to rise. Billy did not get any better in November, and after he had been failing to thrive for more than six weeks, his parents took him into town to the chemist, who gave them some unspecified medicine. This does not seem to have helped and Billy got slowly worse over the next two weeks.

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What did people do when they were sick?

After being weaned, Billy was unwell for more than three months in the spring and early summer of sub-tropical south-east Queensland and over that period his mother recorded that she and her husband sought medical advice from a range of people. They obtained a patent medicine from a neighbour; they went to a chemist in Brisbane twice, and seem to have bought and administered the medicine that the chemist advised; and they took Billy to a doctor in town and gave him the powders that were prescribed. In the second week of January, Billy got worse and his parents consulted one of their neighbours, who diagnosed convulsions. They then called in another doctor, who came out to the farm to see Billy and prescribed medicine that had to be picked up from town and administered every half hour. When called in a second time, the doctor said that Billy had gone too far, and that he could not do any more. Mrs Clifton recorded her sons last night in her diary: Little Billy grinding his teeth first part of the night. I lay beside him to warm his hot hands & give him his medicine. But he got worse throughout the night and could not keep anything down. Billys father went to a neighbour for help, but the advice was that nothing could be done for the child. His parents sat up all night trying to ease Billys distress, but: about a few minutes to 5 oclock I gave the little son some warm brandy & water & he seem to swallow it. & that was his last. The little bird had flown, so peaceful and quiet, to the Lord who loved the little Lamb, my poor little Billy This was a world in which the advice of a doctor seems to have been well down the list in the hierarchy of resources that might be called upon. For Mr and Mrs Clifton, doctors were among the most expensive options for treatment and advice, but that does not mean they were necessarily considered the best, either in terms of efficacy, or in terms of the comfort they were able to provide. Little Billy died in association with weaning and teething, and while twenty-first century explanations might focus on the weaning, and hence exposure to a greater range of bacteria in his food and drink, Billys parents may have understood teething to be the cause of his death. They certainly gave him one mixture (chlorodyne) designed for teething infants, and on the advice of the chemist they may have given him others, such as Stedmans Soothing Powders, or Mrs Winslows Soothing Syrup. The two doctors who saw Billy are unlikely to have had anything more effective to offer him than these opiate-based treatments, and they were unable to prevent his death. The causes of the fall in infant mortality in Australia, especially after the 1890s, are still the subject of debate, but the currently favoured explanations do not involve better medical treatment. They involve some combination of better educated mothers, improved personal hygiene, falling fertility rates and hence fewer small children in the family, better nourished mothers and rising living standards, acceptance of the germ theory of disease, fewer bacteria in the cows milk and in the water, and improved sanitation. We should not assume from this, however, that people like Billys parents delayed in consulting a doctor because they did not believe it would help and the cost may well have been a barrier. Mr and Mrs Clifton seem to have been quite typical of late-nineteenth-century Australians

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in using patent remedies and consulting friends and neighbours before they called a doctor. The story of Jenny Brown, for instance, who died in 1905, illustrates a very similar pattern of behaviour.46 Jenny Brown, aged eight, lived with her parents in a small settlement near Toowoomba. One autumn afternoon, she returned home from school complaining of pains in her stomach. At various times over the next week she was given castor oil and a Health Restorer pill by her mother, and aconite and ipecacuanha by the local Lutheran Minister. Her mother also tried poulticing her stomach with hot bran. According to her father, that gave her relief, but her improvement was short-lived. When the Minister was called in again, he advised taking Jenny to Toowoomba to see a doctor. However, it was raining and their cart was an open one. Mr Brown decided to wait until the morning, by which time his daughter was dead. Distance from a medical practitioner was probably a more important factor in this case than cost, but the next example illustrates powerfully how poverty and isolation might combine to effectively prevent access to medical care. On 20 March 1894, in Geraldton, Queensland, an inquest was held into the death of a miner.47 He was too sick to work, unable to afford food, and sharing a tent with another man. He may have been suffering from difficulty in urinating, a common problem among men as they age. In the 1890s, the standard treatment was to teach the man how to use a catheter to draw off his urine, and a significant proportion of such men subsequently went on to many years of what was called catheter life. When it became too difficult to insert the catheter, or the resulting bladder infections became too painful, surgeons had developed a range of options for dealing with the problem. The death rates from surgery were high, but without some form of intervention, retention of urine was fatal. At the inquest into the miners death, a police constable showed the court: the piece of wire Deceased used to use to make his urine with. There is no record as to whether the miner had ever had a catheter, or whether the piece of wire was a wire catheter, but it appears that he did go to the Geraldton Hospital in search of treatment. The wardsman from the hospital remembered him and told the court that admission was refused.48 At that point, the miner seems to have given up trying to get any treatment, although he could in theory have applied to the Police Magistrate to certify that he was destitute and authorise government payment for a doctor. His mate, whose tent he was sharing, is recorded as saying: I told the deceased several times to come and see the Magistrate and get an order to see the doctor. He did not do so. The official cause of death was: Want of proper nourishment and improper instrumentation. Although retrospective diagnosis is always unwise, it is tempting to see this as a case where poverty denied a man access to treatment that may have saved his life, at least for a while. A similar conclusion might also be considered in the case of a swagman who died in 1905. He was found lying beside a waterhole half-naked, and according to the post mortem report, he died of a strangulated hernia and intense inflammation of the bowels.49 Operations to repair hernias, including urgent operations where the gut had become blocked or strangulated, were a part of the standard repertoire of surgeons by 1905. But while extreme poverty may have contributed to the deaths of the miner and the swagman, the inquest files are full of cases where people who were not destitute failed to seek medical advice, or refused further advice. As late as 1930, for instance, a blacksmith in Scottville was recorded as having died of

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nephritis and heart failure without seeing a doctor.50 His landlady reported that he went to lie on a couch instead of eating his breakfast, and asked her for Aspros.51 Even when they could afford it, many people were not inclined to call a doctor unless they believed that medical advice could help in their specific case. In other words, a certain amount of self-diagnosis was a necessary prelude to calling for medical aid, and in the 1930s, it seems that chest pain was not yet identified as a symptom of a potentially lethal problem, where urgent medical advice might be useful. One widow told the inquest into her husbands death: deceased enjoyed good health except at Xmas he fainted, and on Sunday night prior to his death he complained of a pain in his chest and said he was choking. He brought a bottle of medicine home on the Wednesday night before his death and I thought he had been to the doctor but he had got the medicine from a chemist ...52 Rupture of saccular; aneurism of ascending aorta, was the medical verdict.

The options
There were a number of options available to anyone who was sick, and we have already seen examples of several of them. Almost everyone had access to what was probably the most popular and commonly adopted option of consulting friends and relations and employing home remedies. Those who could afford to pay also had the option of buying one of the many remedies advertised in the newspapers, with or without the advice of the local chemist. Another option was to consult an alternative medical practitioner. In the 1890s there was a thriving medical marketplace with a wide range of services on offer, including from practitioners of homeopathy, herbalism and acupuncture. A fourth option was to employ a nurse. Before the 1890s, nurses were generally untrained, but increasing numbers of formally trained and certified nurses and midwives became available in the early twentieth century. A fifth option, for those who could afford to pay, was to consult a registered orthodox medical practitioner. Not surprisingly, doctors regarded this optionprivate practiceas the most appropriate for anyone who was sick. A sixth option was to pay a small weekly amount and join a friendly society insurance scheme. This then allowed the patient to consult a doctor appointed by the friendly society. The seventh option involved applying for charity. The very poor could apply to a Police Magistrate for certification as destitute and in need of medical assistance, and government funds were then used to pay for a doctor. There were also a number of institutions for those without any means of support, such as the Destitute Asylum in South Australia, or the various benevolent asylums in Victoria and New South Wales. Most of the larger towns also had some form of charitable dispensary, where the poor could queue up for advice and medicine.

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Sally Wilde, The History of Surgery

The eighth option was to go to the outpatient department of a voluntary or public hospital, from where, if their case was considered sufficiently serious or interesting, they might be admitted as an inpatient. During the period 18901940 the outpatient departments of most major public hospitals in Australia dealt with an explosion in patient numbers. Public hospitals were coming to be seen (even by those who could afford to pay) as a place to receive quality care. Doctors called this form of health care provision hospital practice, and from the 1890s there were increasing complaints from doctors that it was subject to abuse by patients who could afford to pay. Of these eight options (generally referred to by doctors as: home remedies, patent medicines, quacks, nurses, private practice, lodge practice, dispensaries and hospital practice), only the first five were notionally freely available to those who could afford to pay. The other three options were supposed to be in one way or another means tested. Chemist shops, alternative practitioners, friendly society doctors and charitable dispensaries mainly provided their patients with medicine and advice. They seldom provided surgical treatment. Nurses, too, provided care and advice but were strongly discouraged by doctors from using instruments. Thus, despite the complex range of options negotiated by patients, in reality they were most likely to encounter someone who diagnosed their condition as requiring surgical treatment if they approached a doctor in private practice, or went to a public hospital. Patients chose their source of medical advice according to their own criteria, which might include religious belief as well as some calculus of cost versus belief in efficacy, or convenience, but the two events most likely to send patients to a doctor or a hospital, and thus to potentially take a crucial step on the road towards surgery, were accidental injuries and difficult childbirth. Another, and increasingly important, highroad to surgery was selfdiagnosis. This was a product of the growing reputation of surgery as an effective treatment. In particular, from about 1900, the publicity surrounding appendicitis fostered the idea that this was a potentially lethal condition, but that it could be cured if it was treated sufficiently early. Many other health problems are now understood in a similar way, including heart disease and cancer, but in the early twentieth century people who suspected they had appendicitis were consulting doctors, while people with symptoms of heart disease more often died without medical intervention. A further high road to surgery was self-diagnosis of a rather different kind, and this chapter includes a few examples from the inter-war epidemic of abortions, at least some of them self-inflicted.

Doctors and childbirth


William Harper, a selector who lived just north of the dairy-farming town of Warragul in the south east of Victoria, kept a diary for most of his working life, but he hardly ever mentioned doctors except when his wife was giving birth: Sunday 21st Mary Very bad at night sent for the Doctor bob went for him could not find his horse

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Monday 22nd September 1884 Baby Maggie Born at half past one o clock. Mary got over it very well. I went down to stop the doctor from coming gave him 10/6 and 10/6 remains to pay for starting to come up. Went down to the township in the afternoon to register it Called it Margaret Mary. got packet sedlitz Powders 1/6 and Bottle Ess peppermint 1/-.53 Because the doctor could not find his horse (but was paid his fee anyway), Mary Harpers first baby was born with the aid of two women, one of whom was a neighbour and the other may have acted as a combination of midwife and what was called a monthly nurse. She was paid for her services and stayed for a week after the baby was born. In William Harpers careful accounting, a guinea for the doctor was a large sum, and no doctor was called for the second birth 15 months later. In all, Mary and William Harper had 8 children between 1884 and 1900 and so far as can be determined from Williams diaries, they called in a doctor just twice. After each birth, though, the new baby was taken to see the doctor in Warragul for a smallpox vaccination. If the diaries are to be believed, William Harper himself did not consult a doctor once in this entire period. The evidence from diaries such as this is very fragmentary, but it confirms what we have already seenthat doctors were not the first or most obvious source of advice when someone was in pain. Family, neighbours and the local chemist were all likely to be consulted before there was a decision to resort to the expense of a doctor. But when a doctor was called, it was most likely to be because a woman was having difficulties during childbirth. By the 1890s, it was a long-established truism among doctors that obstetrics was a way in to a large general practice. The family, so the story went, called on a doctor to attend at a birth and, if all went well, they subsequently called on him (or her) for everything else. Leaving aside the fact that many, if not most, births took place without the presence of a doctor, and many more families could not afford to call on a doctor for anything else, it is possible that childbirth played an important role in the growth of surgery. The importance of gynaecology in the early years of modern surgery has long been noted, and there is a strand of scholarship that links the repair of perineal tears, the removal of ovaries, and caesarean section to some sort of sexist assault by surgeons on the female body. But there is an alternative interpretation. Gynaecology grew, because women called on the services of doctors in ways that men did not. Women consulted doctors in childbirth, and received internal examinations. This consequently exposed them to the possibility of diagnosis of an illness susceptible to surgical treatment. Asking for the help of a doctor during childbirth thus had the potential to put women on the bottom rung of a ladder of clinical interactions, which might lead them on to the point where they were persuaded to submit to surgery.

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Accidents
While women were most likely to call on a doctor during childbirth, many of the men who

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underwent surgery did so because they had had an accident. The necessity for medical assistance might seem self-evident following accidents where fractures and lacerations were regarded as requiring setting and stitching, for instance. In the late nineteenth century, ambulance services were often set up on the basis of precisely this attitude. In smaller towns and rural areas, friends often took accident victims to hospital. In the cities, ambulances collected the victims of traffic and other accidents and routinely took them to the nearest public hospital for surgical repair. Traffic accidents were common long before the internal combustion engine contributed further to accidental injuries. Horses could and did run away with their riders or drivers, like the one harnessed to a dog-cart that veered across Wickham Street in Brisbane in 1900, colliding with a buggy coming in the opposite direction.54 The driver of the dog-cart was flung out onto his head and was taken to the Brisbane hospital by ambulance. Industrial and mining accidents were also common and men might find themselves facing a doctor multiple times because of some combination of an accident and the requirements of workers compensation insurance, as the story of Harry Taylor demonstrates. Mr Taylor worked as a labourer at the Mt Isa mines. In August 1929 he had an accident which resulted in bruising and internal injuries.55 He was examined by a bewildering array of doctors, and certified as fit only for light work. Many months after the accident, he told a trade union official that: Mt Isa Mines Ltd were good enough to give me a light job I worked only six or seven weeks and again became disabled from the injured breast bone. I then entered Mt Isa Hospital and under-went two operations, one for rupture and the other on the breast bone. I am still disabled and unfit, even for light work The union official said that Mr Taylor told him: I will have to do something very quickly Dan, I am getting bloody light on for cash. By this stage, his workers compensation had run out and he was living alone in an old tent on the Mount Isa Railway Reserve. At the inquest, the magistrate interviewed some of those from neighbouring tents. For a while in March, Mr Taylor went back to hospital, but he complained to his friend about not receiving proper treatment from the Hospital and left against the wish of the Hospital Authorities By April he was in what his friend described to the inquest as a very low condition of health On one occasion he informed me that [a doctor in] Townsville had advised him that a certain bone was out of place in his chest and that if he did not have it removed it would eventually kill him. On 11th May, Harry Taylor was found unconscious and foaming at the mouth. His mates from the surrounding tents sent for the ambulance, which took him to Mt Isa General Hospital where he died the next morning. The immediate cause of death was blamed on the patent medicines that Mr Taylor was taking. This tangled tale of one mans multiple intersections with doctors and hospitals and operations illustrates very well the complex circumstances that could lead a patient to surgery. Harry Taylors choices were constrained by many things including his poverty, his location and his lack of education. In this instance, medical authority was backed by the power of the
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State, and decision-making about his workers compensation, but that does not mean that he submitted to it without complaint. He appears to have had a personality conflict with at least one of the doctors at the Mt Isa Hospital, and in the end, he decided that he did not want to undergo any more operations and that the hospital could not help him any further. He retired to his tent, his mates and his bottles of patent medicine. Surgery, as Harry Taylors case so clearly illustrates, was not performed in a vacuum. It was very much influenced by the surrounding social and cultural circumstances.

Self-diagnosis: appendicitis
Besides accidents, there were a number of conditions where the patient and their friends might diagnose themselves as requiring surgical help. By the 1930s, one of the most common of these was appendicitis, but the growing community view that appendicitis could and should be treated surgically did not mean that those people with symptoms necessarily went straight to a doctor. In 1931, for instance, a railway fettler from Goondiwindi waited until his pain was extreme before consulting a doctor.56 He first complained to his wife about abdominal pain a week before his death. He continued to go to work, but the day before his death, he had fits of vomiting, and his wife advised him to stay at home. He went to work anyway, but then consulted a doctor who ordered him to the Goondiwindi District Hospital. He died under the anaesthetic during an operation for a ruptured appendix. Delay in consulting a doctor was very common, especially when people believed that the operation they thought they needed was likely to be dangerous, like the man who died at Mt Isa Mines Hospital in 1931.57 As he told his brother: he had a pain in the stomach and intended to see a Doctor about it during the past two years In the early hours of New Years Day 1931, he became ill after his night shift as a miner and was taken to hospital by ambulance, telling his brother that he thought he had appendicitis. By the 1930s, despite this mans reluctance to seek medical help, appendicitis was widely recognised as a condition that could be cured by surgery, and there was a general community understanding that delay might be fatal.

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Sad, contested tales


The truth is often hard to find in inquests, and this is particularly so when abortion was suspected. But abortions represent an important part of the history of surgery because in many cases, the surgery was self-inflicted and in many more, the woman claimed that it was self-inflicted. Abortion illustrates particularly starkly the ways in which surgery was affected by the surrounding social and cultural circumstances. Doris May died at Tauntonia Private Hospital, Townsville, on 1 Sept 1924.58 The cause of death was given as puerperal septicaemia and heart failure, and the magistrate ruled that no action be taken against the woman who was accused of procuring the abortion, the doctor or any other person. Doris Mays story unfolds through the inquest depositions like

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a crime thriller. She left Hughenden, where she worked as a hotel waitress, and travelled to Charters Towers, where one witness said that a woman performed an operation on her with a catheter, for which she paid 10. Doris May then travelled by train to Townsville, where she took a room in a hotel. A doctor who attended Doris May told the inquest that she said she had had a miscarriage which was due to her own action He sent her to Tauntonia Private Hospital and operated on her three times. Never the less, she became worse and died about a month after admission to hospital. Doris May paid her fees weekly at first, but when she died there was still what the Matron described as a lot owing. Doris May had a son aged 4, and an estranged husband. Poignantly, she had crossed out Mrs in her bank book and put in Miss. Where abortion was suspected, the police were supposed to interview the woman and find out who was responsible. By claiming that her abortion was self-inflicted, Doris May protected others from prosecution, but sometimes it is fairly clear that the woman herself was responsible. In March 1925, for instance, Margaret Jones was admitted to the Mackay Hospital, with a temperature and an abortion oncoming She was curetted the following morning. The doctor did not ring the police for several days, by which stage death seemed imminent. A friend gave evidence and stated: She told me she was pregnant the day after she came to live with my mother We went into a Chemist shop in Sydney Street. She said to the assistant behind the counter I want to buy a catheter he asked her what kind she wanted I asked her what it was for but she refused to tell me saying I was too young to know anything. Margaret Jones told her landlady that she would sooner throw herself in the river than tell her mother about her trouble. Desperately sad tales of this kind can be multiplied many times from the inquests and from the newspapers.59 We have no records on how many abortions were performed that did not result in death (or an inquest), but this was clearly an operation that was performed quite commonly, especially in the 1920s and 1930s, by doctors, by unqualified practitioners, and by the women themselves, and with very high risks.60

Surgery and social circumstances


This section provides some examples which further highlight the importance of the circumstances surrounding surgery. In particular, the treatment of private patients was not quite the same as the treatment of public hospital patients, and the treatment of institutional patients, in asylums and prisons and Aboriginal Reserves, was different again. In April 1931, a 52 year old woman, Mrs Malone, died under a general ethyl chloride anaesthetic at the Mater Misericordiae Hospital in Brisbane.61 This woman was having the abscesses on her buttocks drained, a procedure performed on the ward by a Resident Medical

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Officer. He began by spraying her skin with a local anaesthetic, but when she cried out loudly and made attempts at struggling I decided then it was too painful to proceed with local anaesthesia so I said to Sister I will give her a general anaesthetic and I asked Sister to procure some ethyl chloride the patient agreed to the anaesthetic being administered. Mrs Malone had been diagnosed by her physician as suffering from chronic nephritis. She was admitted to the Mater Private Hospital and treated there for about four weeks, after which she was transferred to the adjacent Mater Public Hospital, dying the next day. Her relatives assumed that records of her condition would accompany her from one hospital to the other, and that her care would continue to be under the supervision of the same physician, because he was Honorary Physician to the Mater Public Hospital. Neither assumption turned out to be correct: I did not make any notes at the time [said her physician] she was in great pain as a result of the abscesses I think the question of the expense came up and I told the relatives that I could not say exactly how long she would live and that she would require constant attention, because she would be constantly bedridden and would have no control over the bowels and bladder, and that is really why she was taken to the Mater Public Hospital. Her ultimate outlook was hopeless. Deceased really came under the treatment of the Staff [that is to say, the paid staff] at the Hospital when she was taken to the Public Section. The Honorary [unpaid] Physician is really advisory there is no obligation either on the Dr or the nurses to send the particulars from the Private Hospital to the Public Section .
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As this case makes plain, treatment as a public patient and treatment as a private patient were not quite the same thing. From the doctors perspective, the emphasis came to be on the choice of doctorprivate patients could choose who treated them, while public patients were treated by whoever was on dutyan emphasis which incidentally elided the fact that patients in public hospitals were often treated by relatively inexperienced doctors. But from the patients perspective, the difference was one of autonomy. Patients and their friends and family were far less involved in treatment decisions in public hospitals than when they consulted a doctor in private practice. Charitable and public hospitals were generally staffed by a combination of paid resident junior staff and part-time, unpaid (honorary) senior doctors. For the junior doctors, hospital work gave them a start in their careers and allowed them to gain experience in a more or less supported environment. For the senior doctors, hospital practice provided honour, status and clinical experience. However, senior doctors with honorary public hospital appointments made their living in private practice. For those who specialised in surgery, there was an increasing dilemma in the 1890s over which patients ought to be operated upon in their hospital, as opposed to their private, practice. Surgery was expensive, and not just because the doctors who performed it tended to charge more for their services. It was also expensive because surgery generally required post-operative nursing care, and a period of time when

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the patient was unable to work. It was therefore a more prolonged drain on the pockets of patients and their relatives than consulting a doctor and taking any medicine that might be prescribed. While a wide range of people, including labourers and their families, frequently managed to afford to pay for the services of a general practitioner, only the well-to-do could afford to employ a nurse for several weeks, as well as pay for a surgeon and an anaesthetist. In the early twentieth century, the clinical encounter, like almost every other facet of social life, varied by class, and in Australia the provision of orthodox medical care was also structurally racist. Many of Queenslands regional hospitals, for instance, operated an apartheid system, with separate provision for whites and Kanakas (Pacific islanders), whose health was important as workers, particularly in the sugar industry.62 Whilst separate hospital provision was made for Kanakas, suspicious and sudden deaths were the subject of inquests similar to those held for whites, and the inquest into the 1895 death of a cane cutter, described as a native of Santa Cruz, allows us a glimpse of this separate provision.63 A wardsman, described as a Polynesian labourer, gave evidence and said that: I am in charge of the sick kanakas at the Pioneer Estate. He described how the cane cutters mates took him from his humpy to the hospital, and that he died on the way there. There was very little medical provision for Aboriginal people, but where it existed, it was also usually separate and different from provision for white Australians, and particularly likely to be disciplinary and controlling. However, aboriginal settlements do seem to have been provided with an official system of health care, however unsatisfactory, and Aboriginal people living in such places may have had more ready access to orthodox medical care than poor whites, as the following story of the death of 8 month-old Jimmy, in 1931 demonstrates.64 His mother told the inquest that her son Jimmy was one of twins. I remember one Sunday in the evening I was doing my cooking and all the little fellows were playing about and when I went to pick Jimmy up I noticed that he could not stretch his leg out none of the children told me that anyone had hit him. He cried all that night then I took him to Nurse in the morning and she sent me and Jimmy into Duaringa with the truck Jimmy slept all the way and he went off this side of Coomoboolaroo. I mean that he died up to [then] I thought might be the doctor might make him right baby was crying when I took him to Nurse. She did not give him anything she just gave him a bath. She did not give him any medicine. She put a needle in his arm. When she did that he went off to sleep, there was no more crying. The doctor who saw the baby when he arrived at the hospital, already dead, said he had died of a convulsion due to teething, a diagnosis reminiscent of Little Billys death forty years earlier. Whatever the quality of medical care that the cane cutter from Santa Cruz and little Jimmy received, they did receive care, in contrast to those who were destitute, but outside the reach of institutional provision. However, they and their friends and family had virtually no choice
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about the kind of care that they received. They were unable to weigh up the costs and benefits of neighbourly advice, patent medicines and orthodox medical advice for themselves. The decision was made for them by the institutions in which they found themselves. They may also have found it difficult to take the perennially popular course of refusing medical advice of any sort. Not surprisingly, this seems to have been even more the case for people in custodial institutions such as prisons and asylums. We see this, for instance, in the case of a 31 year old woman who was an inmate of the Hospital for the Insane, Toowoomba.65 When she began to display symptoms of intestinal obstruction, the Medical Superintendent assisted another doctor to perform an operation, and when she died very shortly afterwards, he also performed the post mortem. There is no evidence that this woman was ever asked for, or gave, her consent to this process, nor that any of her friends or relatives were consulted.

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Sally Wilde, The History of Surgery

Chapter 2: from buyer beware to doctor knows best


This chapter examines the important late nineteenth-century changes in the power relationships between patients, their families, and health professionals. While chapter 1 was based around the words of patients and their friends and relatives, this chapter examines what doctors said about their patients. Generally speaking, the view that emerges from doctors case records is that patients were people who had to be managed by doctors in multiple ways. Patients had to be persuaded to do what doctors thought was in their best interests, including agreeing to any surgery that might be indicated. But in private practice they were also customers, who had to be persuaded to consult a doctor when they felt ill, and to return to that doctor for any subsequent episodes of ill health. In other words, doctors in private practice regularly tried to manipulate their patients without antagonising them. In public hospitals, however, doctors did not need to worry nearly as much about whether the patients were happy with their treatment and likely to return. In the 1890s, a great deal of surgery on paying patients was performed in their own homes. By the 1930s, in contrast, almost all operations, except in dire emergency, were performed in hospitals, so that instead of being surrounded by friends and family, patients were surrounded by orderlies and nurses and, now and again, by doctors. This move alone shifted the balance of power in the clinical encounter from the patient and their family to doctors and nurses and hospital authorities. But there was another major change in the early twentieth century. In the 1890s, operations, especially outside the major cities, were performed by general practitioners, who also treated coughs and colds, delivered babies and advised patients suffering from anything and everything from typhoid to tuberculosis. Until as late as the 1950s, many general practitioners strongly maintained their right to operate when they saw fit, and argued that any attempt to restrict surgery to people with special qualifications and experience was self-interested and unwarranted. But in practice by 1940, except in remote areas, surgery was well on the way to becoming the province of specialist doctors who did little else. By then, most operations were performed in hospitals by fulltime specialists who called themselves surgeons, whilst denigrating part-time GP surgeons as mere operators. Specialist surgeons tended to be accorded greater honour and status than general practitionersby nurses and junior doctors, if not by their patientsand the culture of hospitals tended to put them at the top of the hierarchy, and patients somewhere near the bottom. These two trendsthe movement of surgery from homes to hospitals and from GP operators to specialist surgeonstogether opened a gulf between the person on the operating table and the person holding the knife. In the 1890s doctors could not take it for granted that patients would agree to surgery. The decision clearly rested with patients and their families, and they frequently refused to consent. As a result, it was not uncommon for doctors to discuss an operation at some length, as they tried to persuade people to submit to surgery. By the 1930s, however, many surgeons simply assumed that they could and should make decisions on behalf of their patients. In

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contrast to the 1890s, 1930s case reports hardly ever documented discussing the pros and cons of surgery with patients and their relatives, and instead, there was a growing body of material indicating that patients were no longer routinely the ones making the decisions. But this does not mean that patients were often operated upon against their will. While this may have happened at times, the major shift within society as a whole was towards accepting that surgeons could be trusted to make decisions in the best interests of patients. In the 1890s, the relationship between patients and doctors, especially when an operation was being proposed, can be summarised as buyer beware. By the 1930s, this had changed to doctor knows best. Published case reports are the main source of information for this chapter, supplemented by the letters, diaries and autobiographies of doctors. In the 1890s, many case reports adopted a chatty style, which can be particularly illuminating, providing information about the attitude towards surgery of the patient, their friends and their doctors. We see this in our first example of the changing attitudes of doctors to patients: delivering babies by Caesarean section.

Caesarean section
In 1891, Dr William Byrne of Brisbane was consulted by Mrs Stuart, who had already suffered one stillbirth, one miscarriage and one craniotomy.66 At the time, the standard procedure where a normal birth was impossible (generally because of a small or deformed pelvis) was craniotomy. The babys skull was crushed with the objective of saving the mother, rather than risking the death of both mother and infant. The public is educated up to expect a large mortality in such cases, and do not blame us, wrote Dr Byrne. In January 1892, assisted by Drs Little and Hardie, he set out to save both Mrs Stuart and her baby through the relatively novel and, at the time, very risky operation to remove the baby through an incision in Mrs Stuarts abdomen. Of course, wrote Dr Byrne, this operation is on its trial, but I doubt very much whether a severe craniotomy can show such a low rate of maternal mortality. The public are educated up to the latter operation, horrible as it is, but they look askance at Caesarean section. Its fatality in the past is no criterion of its future success. The case had been discussed at some length with Mrs Stuart and her husband, and the doctors waited for the husband to return home from work before performing the surgery, in the patients home, by the light of two oil lamps. By the 1890s, anaesthesia and Listerian antisepsis, or the rather later aseptic techniques, were regarded as the key preconditions for the growth of surgery. The principle techniques to prevent post-operative infection, and hence give patients a chance of surviving major surgery, involved either attempting to kill any bacteria in and around the wound (antisepsis, particularly associated with British surgeon Joseph Lister), or the newer ideas associated with trying to keep bacteria out of the wound (asepsis). Both methods derived from versions of germ theory, the belief that bacteria were the cause of post-operative infection. What was variously called safe, antiseptic or aseptic surgery gave Dr Byrne and his colleagues hope that they could save both mother and child, and clearly, the three doctors involved thoroughly enjoyed the whole procedure. When it was reported to the Medical Society of Queensland in

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February, Dr Little said he had had the pleasure of assisting at the operation, and was much impressed with it as an alternative to the difficult and clumsy operation of craniotomy. Dr Hardie (who gave the anaesthetic) also contrasted the operation with craniotomy and said that Dr Byrne had operated very brilliantly, and he could say that he had never enjoyed an operation more. Mrs Stuart, according to Dr Byrne, was: a plucky little Scotch woman, who (no matter what her condition was) always said she was much better, thank you67 This was an operation that saved at least one, and possibly two, lives in a very dramatic fashion. It was certainly a positive experience for the doctors, increasing the likelihood that they would have the confidence to attempt to perform it again, and it may well also have been a positive experience for Mr and Mrs Stuart and their friends and family. Operations like this helped to spread the reputation of surgery for working wonders and saving lives. Mrs Stuarts surgery was performed in her own home and she did not die of post-operative infection. But by the 1890s, a trend was already well underway towards performing operations in the specialist environments provided in hospitals. Partly this was because the tools and techniques associated with belief in germ theory were becoming increasingly complex. But there were other factors to consider, including space, lighting, equipment and nursing care. J. Lockhart Gibson, who specialised in diseases of the eye, ear, nose and throat, liked to hang the patients head downwards during adenoid surgery, and in 1896 he reported that he took his own operating table with him to private houses, because it had a special support for the patients head.68 Clearly, it would have been more convenient for him to persuade the patient to come to the table, rather than taking the table to the patient, and eventually that is what happened. But specially constructed operating tables were not the only equipment needed for surgery. In 1897, the Professor of Anatomy at the University of Adelaide assisted at an operation on a woman with multiple ovarian cysts, and described the procedure in his diary. The operation took place on the patients kitchen table and despite putting blocks under the table legs, the patient was still not in the best position to provide the surgeons with good access. The room was small with terribly bad light, so that in addition, it was difficult for them to see what they were doing. There was no electricity in the house and they were: Afraid to use a candle on acct. of ether. In addition, the silk they were using for sutures kept breaking, and it was difficult to stop the bleeding. The overall result was a disaster. Will be careful in future not to allow (if I can prevent it) an operation of such a serious nature being undertaken in a room with bad light and rotten silk, he wrote. The patient died three days later.69 the light and surroundings [were] totally unfit for the performance of a serious operation, wrote another Adelaide doctor in 1900. The patient was sent to one of the growing number of private hospitals.70 In this context, the description of a major abdominal operation in a private home in 1900 by a country practitioner from Millthorpe in New South Wales sounds positively old-fashioned: Everything having been got ready before Dr. Keltys arrival, the operation was promptly carried out, Dr. Kelty administering chloroform and Mr. Hochey, our local chemist, assisting me, wrote Dr Fullerton.71 In 1910, Melbourne surgeon Douglas Shields removed a stone from the Countess of Dudleys ureter in the ballroom of Government House. But while the

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very wealthy might continue to have their surgery at home until well into the 1930s, for most people the clear trend by 1900 was already towards going to hospital for surgery.72 In April 1921, a doctor published a case report of another operation for Caesarean section (performed in hospital), and the differences between this report and that of Dr Byrne thirty years earlier illustrate something of the enormity of the changes that had taken place in the interim. The case was published by Dr Margaret McLorinan, Honorary Gynaecological Surgeon, Queen Victoria Hospital for Women, Melbourne.73 The operation of Caesarean section, she wrote, undoubtedly saved the lives of both mother and child. But Dr McLorinan was no longer interested in this now almost routine triumph of the surgeons art. This treatment, she wrote, can only be regarded as a stop gap, since it brings us no nearer the cause of failure of the labour. She was interested in what caused the disproportion between the maternal pelvis and the foetus in the first place, and how to prevent it occurring in the future to this and other mothers. The mother herself has almost totally disappeared from the picture and was described only as A primipara, aetatis 34 years. We are not even told whether she was married. There is no place in Dr McLorinans case reports for any description of the patient, such as the plucky little Scotch woman, who (no matter what her condition was) always said she was much better, thank you This phenomenon is sometimes described as the disappearance of the sick man from medical writing, and it is usually described as taking place with the initial rise to prominence of hospital-based treatment in France, in the late eighteenth century. But for most doctors and patients, the key change in their relationship took place a century or so later. Throughout the nineteenth century, only the poor were treated in hospitals. Everyone else was treated at home or in the doctors surgery. There is now a large body of literature on the history of the doctor-patient relationship, and much of the recent scholarship has emphasised the negotiated nature of nineteenth-century clinical encounters.74 Nineteenth-century doctors in private practice were not dealing with passive, dependent patients, but with people, often accompanied by family or friends, who had sought out a doctor for their own reasons, frequently questioned diagnosis and treatment, and went elsewhere if they were dissatisfied. Even if the patient was incapacitated, this did not mean that their family and friends were not able to actively examine treatment options on their behalf. In such circumstances, consent had to be obtained before surgery was performed. However, the amount of effective autonomy enjoyed by patients declined dramatically in the early twentieth century, and the associated vivid case note images of them as distinct individuals became increasingly uncommon. This did not necessarily mean that all doctors treated the disease rather than the whole person, but in general, as patients moved from their homes to hospital, they moved from being customers to being clinical material. This change in the attitude of doctors was associated with a marked shift towards increasing medical control.

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Obtaining consent to surgery


In the 1890s, patients and/or their relatives frequently refused to consent to operation. For instance, in 1890 one country doctor from New South Wales wrote the following about a Chinese patient: We explained the nature of the case as well as we could to himself and friends, telling them that the only possible treatment was amputation at the shoulder joint. This they distinctly refused to allow75 Public patients also sometimes refused treatment. In 1897, for instance, a patient diagnosed with an ovarian tumour at the Ballarat Hospital refused surgery and left hospital against medical advice.76 She finally agreed to surgery two years later following a miscarriage, but again left hospital against the doctors wishes, although repeatedly advised to remain. She died two weeks later. It is clear that if patients refused the suggested treatment, then attempts were often made to persuade them. In1900, G. A. Fischer reported a private case of septic sinus thrombosis in a 14 year-old boy where The parents would not consent to his immediate removal to a private hospital, nor to the radical operation77 At that stage, Fischer performed minor surgery instead, but a week later, the boy was worse and he ordered the boys removal to the private hospital for operation (which was successful). Before they agreed to surgery, patients had to overcome their fear, they had to be able to afford the treatment and, above all, they had to believe that surgery would help them. However, not all surgery achieved the desired outcomes. As has already been shown, when patients died in suspicious circumstances, their case might be investigated by the coroner, and when the patient survived but thought they had been treated badly, there were a number of options open to them. They might complain to friends and neighbours, affecting the doctors reputation; and they might refuse to pay their doctor and/or sue if they were unhappy with the outcome of surgery. In 1891, for instance, Mr Gore from the Shotover district of the South Island of New Zealand sued Dr Batchelor of Dunedin, following knee surgery.78 The case was heard in the Supreme Court of New Zealand at Dunedin. In fact, doctor and patient were suing each other, the one for unpaid fees and the other for damages. The court found in the doctors favour on this occasion, and the courts seem to have generally been more likely to find in favour of registered allopathic practitioners than quacks, who were successfully prosecuted far more often.79 However, a case that raised considerable interest in 1895 concerned a patient with a broken arm, treated by a duly qualified and registered doctor.80 Mr Cunneen, a young resident of New South Wales who had been thrown from a horse and fractured his arm, successfully sued Dr Cooper, because his arm was stiff and withered following treatment.81 In this instance, at least some doctors drew the conclusion that it was wise to inform patients of the possible good and bad outcomes from surgery, and advice to that effect began to appear in the medical press. Later in 1895, in an article in the Australasian Medical Gazette, for instance, George Mullins outlined how he thought doctors ought to behave in order to protect themselves from litigation. Doing their duty according to the best of their ability was not enough. A charge of carelessness or incompetence, or even a worse offence might be brought by an unscrupulous or discontented patient whether in hospital or private practice. In cases of injury, doctors should:

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ask for a second professional opinion as soon as possible. If this be impracticable, explain the nature of the case fully to the patient in the presence of some reliable witness In cases of fracture always explain the possibility of deformity or bad union.82 In a 1900 article on operation for inguinal hernia, Charles MacLauren wrote: When advising operation, it is necessary to state to the patient(a) The likelihood of permanent cure; and (b) the risk of the operation, not only as regards life, but in other ways, as regards the patients comfort and his reproductive powers.83 During an 1899 discussion on a paper on appendicectomy by Sydney surgeon Dr Clubbe, Dr Hyde from Clyde, New Zealand put forward the following conundrum: Supposing a practitioner advised the operation while the patient was in a comparatively good state of health, and, although he backed up his advice with the very best of reasons, the patient refused, and, worse still, was so inconsiderate as to remain perfectly well for years; what, he asked, became of the reputation of the unlucky practitioner? Was it not human nature for the patient to brag of his perfect health, and point to the practitioner as an example, and say: That doctor wanted to cut me up. On the other hand, if the practitioner did operate and death resulted, what then became of the practitioners reputation?84 Dr Clubbe replied:
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Of course, surgeons must put up with those contingencies. In urging an operation on his patients he always put before them the full facts of the case. He said, You have a certain trouble going on in your appendix. You have had an attack; you may never have another in your life; but you may have one again next month which may prove fatal. Therefore I advise you to make arrangements to have your appendix removed. In such a way he always put the matter before his patients, and he thought it was the best position for a surgeon to take up in the matter.85 This exchange illustrates the importance attached to discussing options and possible bad outcomes with patients, and the relative autonomy of patients in deciding whether or not to allow themselves to be operated upon. Private patients in particular had to very specifically agree to any surgery, and private patients generally played a very important (if not dominant) role in the business of making a medical living. But this exchange also illustrates the importance attached to a doctors reputation and the role of public opinion. The press in particular had considerable power to influence the behaviour of doctors, quite apart from any action by the courts. In this environment, informing the patient about the risks associated with any proposed operation played a number of important roles. It informed patients and their friends of the problems they might encounter, and it may well have helped to protect surgeons from subsequent censure of whatever kind. But it also fostered trust, and

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this in turn played an important role in persuading patients to consent to surgery in the first place. Clearly patients had to trust doctors, and believe that they could make them better. As one doctor put it: consent resolves itself into a matter of personal faith on the part of the patient in his medical attendant.86 But before patients could be expected to trust doctors to perform surgery, doctors had to have confidence in surgery themselves. By the beginning of the twentieth century, this trust was becoming increasingly common, but in the 1890s we catch a prolonged medical moment when patients did not yet routinely have confidence in surgeons, because surgeons were in the process of acquiring confidence in themselves. In the closing decades of the nineteenth century, surgeons came to believe that infection-free surgery was possible and this confidence, which was at base a belief in both science and progress, was communicated to their patients. Sandford Jackson, looking back over his career in Brisbane wrote: The successful results of surgery in this city had one effect of which one cannot approve. We felt the effects of it for many years in our hospital. Medical practitioners became so fascinated with the art of surgery that few of them could find room for any similar ecstasy when they contemplated the art of medicine.87 There seems to have been something of a snowball effect in the 1890s, as doctors gained experience and hence the confidence to recommend surgery to their patients. As a Melbourne surgeon put it in 1899, in an article on skin grafting: until surgeons acquired the greatest confidence in recommending the treatment, patients naturally were unwilling to submit to it.88 The more times they had performed an operation, the more confidently they could tell their patients what to expect, and give them the confidence to accept that doctor knows best. However, the following cautionary tale from 1935 reminds that not all patients agreed with the suggestions or orders of their doctors, just many more of them than in the 1890s. Patient Flees from Hospital Got Wind Up About Operation, ran a headline in the Brisbane Courier Mail in July 1935. The paper reported that a young man in the Perth Hospital for an appendicectomy jumped off the trolley on his way to the operating theatre and ran out into the street in his nightshirt. Chased by attendants, he ran down Victoria Avenue, past the Christian Brothers College, jumped into the river, and despite the intense cold swam over to South Perth and took refuge at a friends place.89

Conclusion
Traditionally, surgery on private, paying patients was performed in their own homes, or in the doctors consulting room (called the office in North America, but surgery in Britain and Australasia). This changed in the late nineteenth and early twentieth centuries, as doctors attached increasing importance to the conditions surrounding their operations (including the quality of light, the availability of specialist equipment, cleanliness and pre and post-operative nursing care), and as major surgery became more common. However, clinical relationships in hospital tended to be very different from clinical relationships in the patients own homes. Hospital medicine was associated with both greater authority for the

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doctor and reduced autonomy for the patient. As a result, in the early twentieth century there was an increase in the proportion of patients who had little or no effective autonomy in their relationships with the medical system. There seems to have been considerable local variation in the timing of this change, and it also varied with the financial and domestic circumstances of the patient. At any point between 1850 and 1950, the poor everywhere were always more likely to have any surgery performed on them in hospital, while the rich were always more likely to be operated upon at home. Medical authority could not be taken for granted in the 1890s, particularly in private practice. But the phrase I ordered appeared increasingly frequently in published case notes in the early twentieth century. While we may suspect that in some instances, especially at the beginning of the period, the phrase contained an element of wishful thinking, by the 1930s, although GPs might still negotiate treatment with patients and their families, city specialists were increasingly likely to assume that doctors orders would be carried out. The phrase had become a straightforward statement of fact. The doctors ordered and the patients did as they were told.

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Chapter 3: Going Under the Knife


By the early twentieth century, public hospitals in the major cities, whether set up by the Catholic Church or by some combination of government and charitable funding, were coming to dominate the hospital landscape. They were big and they were getting bigger. The Brisbane Hospital, for instance, had 242 beds in 1900, more than twice as many as the next largest hospital in Queensland at Rockhampton. The average size of Queenslands 67 public hospitals was just under 33 beds.90 Private hospitals tended to be even smaller than country public hospitals. In 1926, for instance, there were 480 private hospitals in Victoria, but they had an average of fewer than eight beds each.91 Compared with this, Victorias public hospitals were giants. The Melbourne Hospital was particularly large, with a normal capacity of 378 beds, but the average size of the 57 public hospitals in Victoria in 1926 was 40 beds, and this figure includes the 29, generally small, country base hospitals.92 Even when they were struggling to overcome bad reputations, like the Melbourne Hospital during the erysipelas epidemics of the 1870s and 1880s, they were still the largest and most famous hospitals in town, the places that were most likely to come to mind for members of the public whenever the word hospital was mentioned. By the outbreak of World War I, major city public hospitals were virtually all associated with the training of nurses and in those cities with medical schools (Adelaide, Melbourne, Sydney, Dunedin) several of them were also associated with the training of doctors. The built environment of wards and operating theatres and nurses homes; the rules and regulations for maintaining order and discipline among staff and patients; the larger than life personalities of some of the matrons and gate porters; the traditions and mythologies that built up as generations of young nurses and doctors learned together through the stresses of treating the sick; all these things contributed to investing public hospitals with an aura of solid importance in their communities. But big city hospitals were also in the process of becoming key centres in the moral economy of medicine. By 1900, they were already associated with the traditions of Nightingale nursing, an image of rather nice young women caring for patients within a moral universe where patient welfare came first, and the very idea of a profit motive was not on the agenda.93 On the contrary, trained (female) nurses worked in a world where self-sacrifice was valued and the pursuit of self-interest was not. This was an image that fostered trust and a belief in the good intentions of nurses. Patients did not always accord the same level of trust to doctors in public hospitals, and a hint of the idea of buyer beware sometimes carried over from their dealings with doctors in private practice. But public hospitals were in the process of becoming places where doctors referred their less well off patients for specialist treatment, particularly surgery. General practitioners increasingly associated major public hospitals with specialists. After all, many of them had been taught there, and the implication that they were centres for particular expertise began to be added to the image of these hospitals in the wider community. Publicity surrounding the purchase of major items of new equipment such as X-ray machines fostered the same image of public hospitals as centres for specialist and scientific expertise.

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In 1900, it may or may not have been true that the best or most expert doctors in any particular town were the ones with honorary appointments at the public hospitals. But they were certainly more likely to be well established in their careers than the average general practitioner, and to have acquired a reputation for a particular interest and expertise in a specialty such as surgery, gynaecology, or ophthalmology. Honorary physicians and surgeons at public hospitals had also made the career choice to work for free in a charitable institution for at least part of their time. In cities such as Melbourne or Sydney where appointments were very much sought after, candidates were likely to have been high achievers at medical school and had to have carefully planned their careers over many years in order to be in line for the elite positions. In some smaller hospitals, competition for honorary positions was not quite so fierce, but candidates still tended to be doctors who chose a high public profile, published in the medical press and were active in their local medical societies. The average person in the street was unlikely to have very much information allowing them to decide who was a good doctor and who was not, and that was particularly the case if they believed they needed specialist expertise such as surgery. Going to a major public hospital took the decision out of their hands. They were treated by whichever doctor was on duty when they were admitted. But they had placed themselves under the umbrella of a famous institution where the doctors had already been selected, by whatever means, as competent experts. Public hospitals also, of course, had the great attraction of being inexpensive or even free, but the option of going there was not supposed to be open to everyone. According to the ByLaws of the Brisbane Hospital, for instance, Those who are able to secure such treatment as is necessary in their own homes or in a private hospital were not admissible to the hospital.94 However, although going to the Brisbane Hospital was certainly cheaper than going to a private hospital, the cost being set down in the By-Laws as such sum as the applicant is able to pay, it was not cheaper than staying at home and doing nothing. Patients must have had some confidence that the hospital would be able to help them in some way. It is often very unclear, from a twenty-first century perspective, whether the medicines and treatments listed in contemporary case notes would have been therapeutically effective, but the overall hospital experience almost certainly had a powerful impact on patients, and they may have found this helpful more often than we might at first suppose.

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Brisbane Hospital
On 19 March 1900, a 39 year-old housewife was admitted to Ward 7 of the Brisbane Hospital, the gynaecology ward, having been assaulted by her husband. She spent two weeks there and was discharged relieved on 3 April. This woman had ten children, the youngest six months old, and it is hard to escape the conclusion that the main thing the Brisbane Hospital had to offer her was a rest. The gynaecology ward was also a safe environment, where she might be subjected to repeated vaginal exams and regular enemas, but where she was at little risk of being kicked or hit, except possibly on Sunday and Wednesday afternoons between 2 and 5p.m. when her husband was allowed to visit. On ward 7, she was fed regularly and her appetite was described as very good. The foments she received to the swelling on her vulva where she had been kicked by her husband possibly made a relatively minor contribution to her recovery.95

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Public hospitals of this era are sometimes characterised as terrible places where the poor went to die when they had nowhere else to go; as places to be avoided if possible, where surgery was less safe than if performed at home, and where you were unlikely to be cured of whatever ailed you. Certainly many of the Brisbane Hospitals patients left uncured, and some died. In March 1900, there was a 62 year-old selector (farmer) on Ward 1, for instance, who died following surgery for his kidney stone. But a large majority of patients left hospital cured or relieved and public hospitals were becoming places where less well off members of the community could go for treatment that was likely to be just as good as, if not better than, the treatment they could get anywhere else. Of the 3,241 patients admitted in 1901, for instance, 2,584 or 80% left cured or relieved.96 In 1900, the Brisbane hospital had well ventilated wards with wide verandas where trained nurses provided 24-hour care. A sewerage system had not been installed, because of the expense, but there were earth closet toilets and water was pumped to a tank at the top of the tower above the four oldest wards. Besides piped water, parts of the hospital (but not yet the operating room) were connected to electricity, and there was also a telephone service. Patient charts for this hospital have survived for the early months of 1900.97 Many hundreds of them are bound into one enormous volume, and they offer a glimpse of the daily routines of care in this colonial hospital.98 The basic chart consists of a single sheet of paper with patient details on one side and a grid showing daily temperature, urine and bowel movements.99 On the reverse is the patients story. The terms used are medical and these are not the patients own words, but never the less, we are provided with the patients version of why he or she was there, as mediated by a member of the hospital staff. This patient story is sometimes notably different from the official diagnosis appearing on the other side of the same sheet of paper. Patient states that five years ago her right foot was broken A month ago lost power in her R instep & has difficulty in walking goes one story. Hysteria, SSQ was the terse official verdict on her problem. As has already been noted, patients were only allowed visitors twice a week, so that once admitted to hospital they were effectively separated from their family and friends. Instead, they were placed in the company of fellow patients of the same sex who had been classified in the same way. At the Brisbane Hospital, there were wards for medical patients, surgical patients, gynaecological patients and patients with fever, as well as a number of smaller wards for patients classified as alcoholic, or with venereal disease, or with wound infections. Besides their fellow sufferers, patients would have seen wardsmen on a regular basis and, on the main wards, their day to day care would have been provided by nurses. In each patients record, their own story of why they were there was followed by notes made by the nurses. There were entries concerning the treatment and medicine prescribed by the resident medical officer (RMO) on his daily rounds and by the doctor in charge of the case during his less frequent appearances. According to the By-Laws, each nurse on going off duty was supposed to write in a book kept for that purpose a report of the condition of the patients, and the notes in the case records indicate that this procedure was followed fairly systematically, with notes from both the day and night nurses entered almost every day.

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Nurses and the hospital hierarchy


There is considerable evidence that nursing itself made an important contribution to recovery, quite irrespective of any medicines or other treatments. The Head Nurse at the Brisbane Hospital from 1893 to 1904 was Miss L. C. Marks, and there was also a small number of Charge Nurses, each responsible for a group of wards.100 The main wards had one qualified nurse and one trainee on duty during the day, while nurses on night duty covered a small group of wards. In early 1900, the nurse responsible for the surgical wards and the Operating Room, was Charge Nurse Charlotte Smith. She began working at the Brisbane Hospital in 1891, passed her exam in 1894 and was appointed Charge Nurse in 1896.101 Apart from Miss Marks, she was the most senior nurse in the hospital. There were six other trained nurses on the surgical wards, and they all worked twelve hour shifts, as did the six trainees, only one of whom was on duty at night. Nurses were trained on the job, and besides considerable emphasis on cleanliness (their skirts were shortened to keep them out of the mud and dust), they were taught to use the latest technological assemblages, including thermometers and patient charts.102 Patients had their temperatures taken at 6a.m. and 6 p.m. every day, unless they had a high fever, when their temperature was taken more often. The resulting readings were plotted on a pre-printed grid on the front of their notes. Temperature charts played a vital role on the fever wards, but they also played a key role on the surgical wards. Whatever the combination of cleanliness and asepsis favoured by a particular surgeon, post-operative infection remained a major risk for surgical patients until the arrival of antibiotics in the 1940s. While inflamed and suppurating wounds provided one kind of visible sign of a problem, changes in the patients temperature as plotted on their chart provided a different sort of visual sign, including a display of the progress of infection over time. Changes in temperature were also read as clues to what was going on inside patients suspected of having conditions such as appendicitis or kidney infections, and an elevated temperature was treated as clear evidence that something was wrong, whatever the patients other symptoms. According to the By-laws of the Hospital, nurses were supposed to: preserve order and decorum among the patients The wards sometimes accommodated as many as 20 patients, and on the male wards, many of the patients were young manual workers and most of them were single. They were all subjected to the discipline of a small number of young, single women. The hospital could have been a raucous place, but the Annual Reports chose to emphasise that it was a place of order, discipline and routine. Between 1883 and 1898, the Medical Superintendent was Dr Ernest Sandford Jackson and in 1899, the Committee of Management attributed the excellent discipline of the whole staff to a great extent to his judicious government. 103 Florence Chatfield worked with Dr Jackson for many years and remembered him as stern, but fair: Of him delinquents walked in dread, but those who conscientiously sought to do their duty had no cause for fear 104 In 1898, Dr Jackson joined the honorary staff as one of the three visiting surgeons and his place as Medical Superintendent was taken by Dr James ONeil Mayne. Dr Mayne was later famous as a major benefactor of the University of Queensland, but in 1900 he was known as a loyal disciple of Dr Jacksons methods. The other doctors treating patients on the surgical wards in

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early 1900 were Drs Thomson and Marks. However, they only visited once or twice a week. The doctors whose day-to-day presence regulated treatment were the two surgical Resident Medical Officers. One of these was Dr Harding.

Dr Hardings day on Ward 1


One of the strategies that young doctors adopted to try and improve the reliability of outcomes from their operations was to build up their experience of the processes of surgery itself, such as cutting and sewing tissues, whilst performing minor procedures. The treatment of cuts and lacerations following accidents, for instance, offered scope for this kind of practice, and most nineteenth-century hospitals provided plenty of patients with abscesses to drain and ulcers to dress, so that doctors could observe the behaviour of infected tissue under varying conditions. By 1890, the old system of apprenticeship-training for surgeons had come to an end and was in the process of evolving into a new system for the post-graduate training of generic doctors in the specialty of surgery. But meanwhile, the positions of paid RMOs in major hospitals offered at least some young doctors the chance to acquire basic surgical skills before they went into practice on their own account. Public hospital positions gave them the opportunity to watch and assist more experienced surgeons at work, to see on the wards how patients fared before and after surgical treatment, and to practice minor surgical procedures themselves. Every morning, RMOs at the Brisbane Hospital had to visit the bedside of each patient under their care and they also had to visit each of their wards again every afternoon. On 29 March there were seventeen patients on Ward 1, including two who left during the day and two new patients.105 The residents of Ward 1 were aged between 15 and 62 (children had their own hospital just up the hill), and some of them had been living on the Ward for months. Five of the men on Ward 1 that autumn Thursday had been admitted as a result of accidents and had injuries which included infected wounds. Three men were there because of long-term abscesses or skin ulcers of various kinds and four were there for what would now be described as elective (rather than emergency) surgery for their hernia or varicocele. Of the other five, one had TB, one had hydatids, one had appendicitis, one had a kidney stone and one had sciatica. On the 29 March, we know from the patient notes that Dr Harding examined the leg of the 19 year-old man with a knee injury. His infected left leg was suspended in a McIntyre splint and nurses were applying foments to the thigh every four hours. He also re-bandaged the left ankle of the 21 year-old soldier who was complaining of burning heat in the foot and heel. Then there was the 48 year-old labourer who had had an operation for hydatids on 21 March. His wound was inflamed and Dr Harding ordered it to be bathed with carbolic and dusted with boracic powder. Another patient, a 25 year-old labourer, had also been operated upon on 21 March, but for hernia. Dr Harding bathed his wound with carbolic, too, and the pillows were removed from under the patients knees. Dr Harding also inserted an exploring needle into the abscess on the back of the Wards long-term inhabitant, the 18 year-old

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grocer. This patient was then prepared for an operation at 11.30 the following morning (which he later refused to undergo). Dr Harding also saw a 21 year-old soldier recovering from a varicocele operation and the newly admitted 62 year-old selector with a kidney stone. But the big event of the day on Ward 1 was at 10.45 a.m. when the 15 year-old school boy was taken to the operating room for surgery. Those patients who were operated upon had the details of preand post-operative care recorded in their notes and sometimes, particularly in the case of serious or major operations, a paragraph was later added in red ink. These paragraphs appear to represent the words of either the surgeon or the RMO, describing the operation. The following description appears in red ink in the notes of the 15 year-old boy: Operation: The Patient under ChloroformAn incision was made over the swelling on left sideThe sac being dissected out was found to be continuous with the Tunica Vaginalis & when opened about 1 oz of serous fluid came away the sac was cut close to the testicle & sutured with silkthe remaining portion was twisted & treated by Balls (Dublin) methodleaden plates.106 Dr Harding assisted Dr Marks to perform this Irish method of hernia repair and the patient returned to the Ward about mid-day.107 Dr Harding then saw the patient again multiple times during the day, ordering hypodermic injections of morphine for his pain and small amounts of milk, which the patient vomited up. At 10.30 p.m. he made his final visit of the day to the school boy, passing a catheter to draw off his urine.

Agency
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Once admitted into hospital, did patients have any power to negotiate how they were treated? The wish, sometimes fulfilled, of doctors to be considered gentlemen has been much discussed.108 But patients also expressed views as to how they wished to be considered, and treated. Hospital patients might be the recipients of charity, but that did not mean that they were always happy to be treated in a manner that did not accord with their self-assessed view of their own status. It should be noted that it was by no means always doctors behaviour that failed to meet patient expectations. Interactions with nurses were just as important in patients experience of hospital life. They could, of course, simply leave if they were unhappy, and in a number of instances, the case notes report that a patient absconded. A 16 year-old boy, for instance, was admitted to one of the isolation wards with an infected foot diagnosed as cellulitis. He had a very high temperature and the swelling in his foot was opened and drained. After four days his temperature fell to normal and he was well enough to eat some bread and milk. He absconded the same afternoon. But did patients have any say in their treatment if they remained in hospital? The case notes provide some evidence that patients were able to refuse surgery, and they also throw some light on whether patients were able to ask for, and obtain pain relief. Patients were clearly able to refuse surgery in theory. According to the By-Laws, No major operation shall be performed without the previous consent of the patient (if in a condition

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to give it), nor unless after a consultation by two at least of the Honorary Visiting Surgeons, who shall initial the record of their decision in the Consultation Book. 109 The Consultation Book has not survived, but there is scattered evidence in the patient notes of occasional consultation between the honorary surgeons. However, consultations between an honorary and an RMO were routine, and Dr Mayne, the Medical Superintendent, was also frequently involved. The notes also make it clear that patients did, sometimes, refuse surgery. We can only speculate as to how often surgeons persuaded reluctant patients or patients persuaded reluctant surgeons and in this context it is interesting that operations were noted as postponed far more often than they were noted as refused. Were postponed operations a sign of patient reluctance? Was the surgeon busy elsewhere? Did the surgeon change his mind? Pain relief is even more problematic. In some instances, morphine seems to have been given as soon as pain is noted in the chart, whereas in other instances, no pain relief is noted, despite repeated records of complaint from the patient. This raises the issue of whether all patients were treated equally, and it is abundantly clear that they were not.

Unequal treatment
The organisation and physical structure of the Brisbane Hospital related to its role as an institution for classifying, segregating and recording changes in various types of infections. An early specialty of the hospital had been the development of strategies for the management of fever. The paradigmatic patient placed on either Ward 8 or 9 had typhoid. These male and female fever wards were in a long, low building, separated by open space from the rest of the hospital, but besides typhoid, they were also used for the management of other infectious diseases such as influenza. Temperature charts, cold or tepid baths and fever diets were the main strategies used to manage patients with such infections. The other spaces for segregating infections at the hospital had been developed on a more ad hoc basis and unlike the fever wards, several of these were spaces for stigmatised exclusion. Some of the patients were not there voluntarily. The site of the hospital encompassed a small wooden building known as the Lock Hospital, for prostitutes diagnosed with venereal disease. It had 20 beds, only half of which seem to have been occupied at any one time. It should be understood that the Brisbane Hospital was not a single building in 1900, but a collection of buildings, some of them consisting of only one or two rooms and specifically designed to be separated from each other. The average number of patients in the hospital on any one day in 1900 was 176, despite the notional bed capacity of 242. In theory, they were spread around 31 wards, but the following year the official ward count was reduced to 20, and the surviving patient charts for 1900 only refer to nine main wards, plus half a dozen tents and annexes. Female patients who had venereal disease but were not prostitutes were separated from the main female medical ward, 6, in what was known as Ward 6 Tent. Male patients with venereal disease were also separated from other patients by being placed in Ward 10, which was another tent. There were also special wards for other sorts of patients, and like the venereal disease wards, they carry a strong hint of stigma. One small ward, for instance, seems to have been almost entirely occupied by men categorised as alcoholics. (Ward 14).

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By 1900, surgery was beginning to affect the structural layout of the hospital. One of the tent wards was full of men with abscesses and ulcers and another was occupied mainly by cellulitis cases. The Brisbane Hospital did not begin to publish details of which operations were performed and how many patients survived until 1901. In that year, the overall mortality rate for patients undergoing surgery was 4.4% (31 out of 704).110 There is no information as to how many of these deaths were associated with post-operative infection. When a wound became infected, the medical staff feared that the patient might not survive, and they believed that the infection might somehow pass to other patients. The hospital was on a relatively spacious site, and so the solution adopted was to isolate people with cellulitis or erysipelas or gangrene by putting them out in a tent. In 1901, the tent wards were given concrete floors. They probably had timber rooves and a system of canvas sides that could be rolled up or down, depending on the weather. Dr Sandford Jackson, who used tents for infectious cases while he was Medical Superintendent, had trained in Melbourne, where similar tents had been in use on a much more crowded site and in a much less suitable climate, for some years.111 In the tent wards, according to some combination of a belief in germ theory and the older ideas about buildings harbouring disease, the powers that be at the Brisbane Hospital had faith that good ventilation and no walls to harbour germs would cut down the risk of passing infection between the wounds of patients. It should be noted that there were no nurses for many of the tent wards, although there were wardsmen, and the patient notes vary from scanty to semi-literate. Life in one of these wards would have been very different from life on one of the main wards, if only because there were no nurses to take temperatures twice a day and monitor bowel movements. But there is also the question of stigma, and compared to the main wards, the tents were, to a greater or lesser extent, stigmatised places of exclusion. They seem also to have been used as places to treat the very few non-white patients in the hospital. There are hints in the patient records that besides varying by sex and by ward, treatment also varied with something harder to pin down. There were patients who were regarded as good and there were patients who were regarded as bad, and they were treated accordingly. There were a number of rules covering patient behaviour. Patients had to take their medicine regularly; they had to be silent during ward rounds; and they werent allowed to eat or drink anything other than their prescribed diet. But this was an institution that people wanted to enter, and the ultimate sanction for bad patients was to be dismissed. This also applied to outpatients. Patients who conduct themselves in a disorderly manner or who do not conform strictly to the Rules, shall be discharged. Besides being expected to be orderly and conform to the rules, if and when their health improved, patients were expected to work: If able to do so they must perform any kind of work at the request of the nurse, and if fit to be employed in the service of the Institution, shall render any assistance that may be required.112 Women patients, for instance, were employed mending hospital linen. Patients on Ward 10 were, almost by definition, regarded as bad. They were all able to walk around and were therefore supposedly expected to help with the work of the hospital, and most were being treated for syphilitic chancres. The standard treatment was to perform

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circumcision (under chloroform) and dress the chancres with Iodoform for two or three weeks. A cane cutter from the Solomon Islands, for whom the official diagnosis was ulcer on root of penis, improved, told the admitting clerk that he had a lick bite. He is recorded as having absconded after 12 days.113

Surgery
On 6 March 1900, Mary Brown was admitted to Ward 5, the female surgical ward. Two weeks earlier, she had been diagnosed as suffering from an ovarian cyst and then discharged from the hospital. Readmissions of this kind were not at all unusual, and by the end of the nineteenth century, many patients had experienced a prolonged sick career involving multiple hospital admissions and multiple operations. When Mary Brown returned to the Brisbane Hospital, she was complaining of an increasingly distended abdomen. She would have been given a warm bath and clean linen before being warded and her valuables listed and handed over to a nurse for delivery to the hospital secretary. The By-Laws of the hospital noted that the nurse should take charge of her clothes and if necessary, have them cleaned or disinfected. Late nineteenth-century hospitals, as David Armstrong has noted, were about beds, places where bodies were examined, rested, disciplined, and kept away from dirt.114 New medical knowledge generated in the hospital and the laboratory was applied to the bodies laid out neatly between clean sheets. Hierarchy and order characterized the modern hospital of 1900, and the application of germ theory to the strategies for dealing with broken limbs, fever, abdominal pain and childbirth brought older ideas about the proximity of cleanliness to godliness into a fearsome alliance with science. From the 1880s, doctors and nurses at the Brisbane Hospital invoked the ideas of cleanliness, fresh air and order associated with Florence Nightingale, quite as much as the concept of germ theory associated with Lister, Pasteur and Koch.115 According to the Annual Report of 1901, there was a general endeavour to bring the appointments of the institution into line with hygienic laws of the present day, including the removal of old wooden casings around lavatories [hand basins] and baths and the substitution of porcelain for enamelled-iron sinks and basins.116 Meanwhile, the technologies of asepsis replaced those of antisepsis in the operating theatre, where the time honoured furniture was replaced by equipment made of glass, electro plate and polished brass. A separate room was set aside for anaesthesia and a large sterilizer was installed in a new annexe. Three new wash basins were provided with hot water and operated by foot taps, allowing the surgical staff of the Brisbane hospital to scrub up without touching the taps with their hands. On 8 March, Mary Brown was prepared for laparotomy, which involved elaborate cleansing of the operative site. In 1904, Nurse Margaret Henry recorded the procedure for preparing a patient for surgery in her lecture notebook.117 The day before surgery, the hair should be shaved off the operative site and then the skin washed thoroughly with aethereal soap and sterilized water for 15 minutes, frequently changing the water and sterile swabs (use a nail

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brush). The area should then be rinsed and scrubbed with aether for a few minutes, before being washed with a mixture of 1 in 40 carbolic lotion and 1 in 1000 corrosive. A compress of 1 in 60 carbolic and 1 in 1000 corrosive was then bandaged over the site. This treatment of the operative site was supposed to be repeated an hour or two before the operation. At 8.30 in the morning of the 9 March, the skin of her abdomen presumably prepared in a similar fashion, Mary Brown was taken to the operating theatre. The following appears in the notes in red ink: Operation: Under chloroform the abdominal wall was opened by incision thro the layers composing it. A tumour presented immediately in the middle line. This was punctured by a cannula, but the cyst wall was so thin that the wound was larger than the cannula & a white mucous fluid exuded. The patient was promptly turned on to her side & the fluid allowed to escape. Some adhesions between the cyst wall & the mesentery & a very few between the cyst & the bowel were sponged off. A pedicle needle with a thick silk ligature was then passed thro the pedicle & then the ligature was tied around front of the broad ligament of the uterus the R fallopian tube & the right ovarian artery. The pedicle was then cut thro & the cyst removed. Slight oozing was remedied by clamps & the abdominal wound sutured with a single layer of silk sutures.118 Unlike many patients, Mary Brown did not vomit after the chloroform, but she was constipated and the main treatment that she received for the next few days was designed to produce regular bowel motions. The efforts made to regulate and normalise the frequency and nature of the bowel motions of almost all patients at the Brisbane Hospital are a salient feature of both the patient charts and the daily nursing notes. Nurses were generally able to impose order on this aspect of the bodies under their care. Mary Browns wound was dusted with boracic powder and the stitches removed on the fifth day after surgery. She made an uneventful recovery and went home three weeks after the operation. Mary Browns main complaint during her final week in hospital was a swollen face and toothache. Interestingly, the official note read: ovarian cyst, relieved (not cured). The implication is that the doctors were not sure whether or not the surgery had fixed her problem. Mary Brown was a member of a minority group at the Brisbane Hospital: women. About 65% of the people treated at the hospital in 1900 were men. Partly, this was a result of the preponderance of men in the population of Queensland, but the sex imbalance in hospitals was far greater than the sex imbalance in the population as a whole. It may be that women were less inclined to apply for admission to hospital, or it may simply be that less hospital accommodation was built for them. At the Brisbane Hospital in 1900 there were 156 beds for men and only 86 for women.

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St Vincents Hospital, Melbourne


At the turn of the nineteenth century, the Catholic Church invested enormous resources in the provision of both private and public hospital facilities. St Vincents Hospital, Melbourne, opened in 1893 and began life in a converted boarding house. Case books for the early years have been preserved in the hospitals archives.119 The records that they contain are far briefer than those surviving for the Brisbane Hospital, and represent clean copies of notes taken by the RMOs and entered into books with the name of the responsible honorary surgeon or physician in gold lettering on the cover. In a few cases, a loose leaf of paper containing a temperature chart is tucked into the book, but generally there are only scattered references to temperature, bowel movements, urine characteristics or pulse. However, although the case books mainly illustrate the perspective of the RMOs and do not contain patient charts, they do also allow glimpses of some features of the hospital experience from the patients point of view. In particular, they provide additional evidence that in the 1890s patients sometimes had lengthy sick careers which included multiple hospital visits and multiple operations, and that surgeons did not always believe that an operation was in the best interests of a patient. Surgical patients at St Vincents had the benefit of treatment by some of Melbournes bestknown surgeons. Honorary appointments at St Vincents did not have quite the status of appointments at the Melbourne Hospital, at least in the early years, but both Mr W. Moore and Mr (later Sir) George Syme were surgeons to St Vincents in the 1890s. In later years, Syme was a key figure behind the founding of the Royal Australasian College of Surgeons, but in the 1890s he was still building his reputation as one of Melbournes most thoughtful and respected surgeons. As was the case with surgeons in Brisbane, for Syme the key question was often not how best to perform an operation, but whether or not to operate at all. Among the first patients that he saw at St Vincents was a 69 year-old grazier, about whom the registrar made the following notes: Six years ago began to notice that he could not pass urine freely & micturition frequent, got better for a time then bad again. Last 3 weeks stopped and has had to have water drawn off with a catheter, after which noticed a little blood. No pain except when bladder gets distended. On examn prostate greatly enlarged per rectum sound passed easily into bladder. No stone detected. Jacques catheter passed by patient easily & urine drawn off Consultation nil to be done not to interfere discharged.120 If the patient was able to pass a catheter himself, then Mr Syme thought the safest option was not to operate. Syme made a similar decision in the case of a woman admitted with a tumour in her abdomen. The walls of the abdomen were very fat and there was sugar in her urine. Mr Syme decided not to operate, wrote the resident. In other cases, however, Syme operated quickly and decisively, as in the case of a young woman admitted in 1897 with symptoms of intestinal obstruction. According to the residents notes: There was no time to take a history before operation. Abdominal section was performed by Mr Syme. Things did not go well, and the woman died a few hours after the operation. There was no post-mortem, but the resident was clearly interested in the case and drew a diagram of the twisted jejunum

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in the notes. He showed where a loop of ileum had passed through a hole in the mesentery and noted that there was general peritonitis. The hole in the mesentery was apparently congenital, he wrote. Tucked into the case book is a folded sheet of paper in a different hand. This may have been a case history written by the womans general practitioner. It contains the following information on the young womans sick career: MC aet 27 domestic. When 4 years old had an attack of spasmodic colic. She suddenly got violent and intense spasms of colic referred to the umbilical region with vomiting and constipation. For treatment they were giving her injections all the time; she was 4 months ill at this time. She was strong and well after this till she was 21 (April 27/91) when she was living in E. Melbourne; she had been constipated for 5 days & she took a large dose of salts; on going down the yard she suddenly had a violent abdominal pain & fell down unconscious; she remembered nothing till they were carrying her upstairs. Dr McColl called in Dr Moore & Dr Fitzgerald who wished to operate but this was refused & she recovered; since then she had been well although subject to constipation. She would often swell up and get much stouter than usual. Her last illness began with constipation pain in abdomen vomiting & some slight feverishness at first. Calomel and enemata refused to act and she was sent to hospital.121 This womans story contains a number of features which should by now have become familiar to the reader. She consulted multiple doctors over a period of time, and refused surgery when it was first suggested. Stories like this gave considerable ammunition to surgeons who argued that refusal to consent to surgery was often not in the patients best interests. They were the ones in the best position to make the complex technical decisions about whether or not it was wise to operate. An operation might prove successful if it was performed when first advised, but it was less likely to be able to help if the patient put off agreeing to surgery until their symptoms were extreme. Over time, the public in general came to accept this surgical point of view, and the associated confidence in surgery that went with it. But in the 1890s many patients still agreed with MC in distrusting the idea of surgery when it was first suggested to them.

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Changing attitudes to patients


The following two case studies demonstrate something of the enormous changes between 1890 and 1930 in the social expectations and attitudes to patients undergoing surgery. Mrs Cann and Mr Flynn were treated at the same hospital, both were working class patients, and both their deaths were the subject of an inquest and considerable publicity in the press. However there were startling differences in how they were treated, not only medically, but also attitudinally. Mrs Canns death in 1890 was followed by a public debate about how she behaved and her personal cleanliness, a debate that involved her friends and family as well as doctors and nurses. Mr Flynns death in 1930 was followed by a public debate about how the doctors behaved. The views of his family were (politely) ignored.

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Sarah Cann
This story outlines the complex route through the medical landscape that led one patient to surgery, and illustrates some of the attitudes surrounding the performance of surgery in Australia in the late nineteenth century. It concerns an instance where an operation with fatal consequences was not investigated, whilst the issue of whether or not patients were kept clean in the Brisbane Hospital was investigated at some length. This story also illustrates how a surgical operation might be just one form of medical intervention among many, in a prolonged period of illness. On 1 January 1887, Dr F. E. Hare introduced the cold bath method of treatment for all typhoid patients at the Brisbane Hospital.122 This treatment, which was also used at Hospitals in Baltimore, Montreal and Stettin, among other places, involved reducing the temperature of patients with fever by placing them in cold baths. The treatment reflected medical understandings of fever that were already going out of fashion by 1900, as ideas on the protective value of fever in killing invading organisms replaced earlier ideas on the dangers of elevated temperature to the body. The patients rectal temperature was taken six times a day and if it reached 102.2 F, (39 C) they were placed in a bath for about 20 minutes at a temperature of 70 to 80 F. (The cost of ice in Brisbanes warm climate prevented the temperature being lowered to 68, as recommended by Dr. Brand of Stettin.) Over the ten years from January 1887 to December 1896, 1,902 patients diagnosed with typhoid were submitted to the treatment in Brisbane, with a mortality of 7.5%. This compared to a mortality rate of 14.8% for typhoid patients in the previous five years. When Dr Hare left the hospital at the end of 1896, the treatment was continued by Dr Eugen Hirschfeld, although he favoured rather warmer baths at 85 F.123 Dr Hirschfeld hinted at some of the differences in the relationships between doctors and their patients in private, compared to hospital, practice when he noted that very few private patients could be persuaded to submit to regular cold bathing, Both the cold bath and the tepid bath treatments relied on the latest technology. Dr Ernest Sandford Jackson started work at the Brisbane Hospital in 1882, and he remembered that one of the main deficiencies was that: there was not in the whole nursing staff one man or woman who had been accustomed to use a thermometer and take a chart. The only thermometer in the hospital was the one in the doctors pocket.124 He set up a training school for the female (but not the male) nurses in 1886. From 1887 at the Brisbane Hospital, the technology package or assemblage of mercury thermometers, charts, wooden baths on wheels, lined with galvanised-iron, wardsmen for the heavy lifting, and trained nurses, made possible the implementation of the cold bath treatment. The typhoid, or rather fever patients were treated in two special wards, one for men and one for women. All visitors were supposedly excluded, because they were regarded by Dr Hare as having a baneful influence on the patients, raising their temperatures. It should be noted that there is no indication that the water was changed between patients. On the contrary, movement of both patients and baths was kept to a minimum and as each patient was lifted out, the bath was wheeled straight to the end of the next bed. However, Hare noted that

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before each bath, patients were made to pass water, as otherwise the shock of immersion in the cold water gave them an almost irresistible desire to urinate in the bath. There was no intent to clean the patients with the cold bath treatment, only to cool them. The treatment was systematically carried out on all fever patients admitted to the hospital, providing an abundance of clinical material, more than sufficient indeed definitely to prove the value of the treatment without having recourse to statistics from elsewhere. This was a controversial treatment, as even Hare acknowledged, citing the British Medical Journal to the effect that the treatment was very much disliked by patients and their friends. Some patients, Hare noted, refused to submit to the treatment, especially in the first year he employed it, but keeping all fever patients together on the same ward helped to overcome this resistance. No difficulty is met with in overcoming the common initial prejudice of patients against cold water in a ward where all alike are submitted to it, he wrote. But the Brisbane Hospitals patient records for 1900 indicate that all was not always well on the receiving end of even the tepid baths instituted by Eugen Hirschfeld, which were supposedly followed by less shivering and were less dreaded by the patients than Dr Hares cold baths. Took it well, is a frequent comment in the notes, or not complaining, both of which remarks speak volumes. The publicity surrounding Sarah Canns death in 1890 offers a window on this treatment from a rather different point of view, providing a messy and complex contrast with Hares disciplined patients and tidy statistics.125 Mrs Cann, the wife of a carpenter, died on 12 April 1890 from sloughing from operation. She had been admitted to the Brisbane Hospital in November 1889, against the advice of her doctor, who thought she had a slight attack of gastric fever and would be better off at home. She remained on the womens fever ward, being treated for typhoid, until early February 1890. Despite Dr Hares prohibition on visitors, her husband, William, did manage to see her several times and noted that she was very ill and had lice in her hair. William Cann decided to try and get her home. He stated that when he took her out of hospital, she was dirty and had an abscess [in her groin] that was running which appeared to him not to have been dressed for several days, and the smell from it was sickening. Bodily odour was a heavily loaded concept by the late nineteenth century, associated not only with uncleanliness, but also with the working class. There were also medical connotations. By the 1890s, ideas surrounding germ theory had almost everywhere replaced the idea of miasma (which incorporated the concept of smell as a marker of danger), in understandings of disease causation. Nevertheless, it is likely that the smell from Sarah Canns abscess would have been considered potentially sickening literally, as well as metaphorically. Her other marked symptom was that both legs were contracted under her, so that she was unable to stand, and on 6 February her husband called in Dr Southam, who practiced as a homeopathic and hydropathic doctor. Dr Southam reported Mrs Cann as saying that her: Condition was the result of the cold water bathsThe deceased said they took her out of the water and laid her on a bed and then put a sheet over her and left her shivering, and the reason she got in her present position was that she

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Sally Wilde, The History of Surgery

doubled herself up to try and keep warm, and she had asked for a blanket but could not get one.126 Dr Southam called on the advice of Dr Marks, who was one of the Honorary Surgeons at the Brisbane Hospital. Dr Marks seems not to have agreed with the medical professions disapproval of consulting with homeopaths and other alternative practitioners and, together with Dr Southam he visited Mrs Cann at her home in Vulture Street on 25 February. They decided that she needed surgery to straighten her legs so that the abscess in her groin could be properly dressed, but they also decided to delay operation because she was too weak. Dr Marks tried to shift at least part of the blame for the patients condition to her own behaviour, arguing that: the contraction of the deceaseds legs resulted through her having a relapse and refusing to have her legs straightened. Mrs Cann was not held responsible for the abscess, but she was held partly responsible for the fact that it could not be properly cleaned and dressed and therefore emitted a sickening smell. Both doctors saw her again on 28 March and Dr Marks advised further delay in performing the operation; but the deceased was anxious to have something done So Dr Marks and Dr Southam forcibly straightened Mrs Canns legs under chloroform and fixed them to a splint. How much experience had Dr Marks had with such cases? Had he ever performed an operation like this before? Had anybody ever performed an operation like this before? The Magistrate did not ask questions of that kind about the surgical treatment (which was carried out at the Canns home in Vulture Street). This is despite the fact that the skin around the joints tore and began to slough a few days after the operation, and Mrs Cann died two weeks later. The omissions in the questioning of treatment at the Brisbane Hospital are also interesting. Neither Dr Marks nor Dr Southam disagreed with the cold bath treatment, and the Magistrate said that: the only question worth inquiring into further was as to whether the deceased was kept clean while in hospital. The Brisbane Hospitals advocate at the Police Court, Mr Mansfield, set out to establish not that Mrs Cann was kept comfortable, or was appropriately treated, but that she didnt smell and if she had head lice, it was because she refused to allow the nurses to cut off her hair. Nurse Irene Handley and Mrs Canns friend, Rose Heaton, were both questioned as to whether Mrs Cann had head lice, and whether her body was clean, at the time she was admitted to hospital. Overall, the inquest into the death of Sarah Cann was not used as a way to find out what went wrong with her treatment and how the death of similar patients might be avoided. Rather, it was used to blame at least part of her problems on her own behaviour, and to cast very public aspersions on her personal hygiene in a social setting in which being clean was about claiming both virtue and social position. That the case was manipulated by a legal representative of the Brisbane Hospital, an organisation rather more powerful than Mr and Mrs Cann, is unsurprising, especially as the Cann family seems to have had no equivalent legal support. But the case also raises rather less obvious questions. Why did Sarah Cann not only agree to, but apparently ask for, the surgery to straighten her legs? She had clearly had a bad experience at the Brisbane Hospital, so why did she have confidence in the homeopath, Dr Southam and the orthodox surgeon, Dr Marks? She and her husband did not just go along with whatever the medical

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establishment suggested. Her husband took her home from the Brisbane Hospital, and the family were involved in making decisions about how Mrs Cann was going to be treated. Mrs Cann was not only a public hospital patient. She was also a private patient, consulting doctors privately both before and after her treatment at the Brisbane Hospital, and choosing at least three different doctors to call in to see her at home.

Thomas Flynn
Mr Flynns death in the Brisbane Hospital was followed by not only an inquest but also a Royal Commission.127 Mr Flynn was diagnosed by Dr Meek on 18 August 1930 as having cancer of the mouth. On Dr Meeks advice, he went to the Brisbane Hospital the following day and was seen by the radium Registrar, Dr Uhr, and the Honorary Radiologist, Dr McDowall. They advised him to have radium treatment for his cancer and he was admitted to the hospital on 21 August. On 22 August, under ether anaesthesia, Dr McDowall buried radium in and around the growth on the floor of his mouth. Mr Flynn left hospital after seven days. According to the report of the Royal Commission appointed to enquire into his death: It was recognised by all the medical men concerned that the radium treatment was to be in no way final, but that it would be followed by a surgical operation for the removal of glands on the right side of the patients neck.128 Accordingly, Mr Flynn was readmitted on 25 September. There is no hint in the language of the Royal Commission that Mr Flynn was in any way involved in this decision. He was: notified to report for further examination, and it was the duty of the Radium Committee to decide upon the treatment to be given to cases such as that of Flynn. Thomas Flynn was given brachytherapy, a form of radiotherapy where radioactive substances are inserted into the body. In 1930, this was a very new treatment in Brisbane. X-rays were discovered in November 1895 by Wilhelm Roentgen, and although they are best known for their diagnostic use, they were also used to treat cancer from a very early date. In Australia, for instance, radiation oncologist Graeme Morgan found evidence that X-rays were used to treat breast cancer in Ballarat as early as October 1896, and that they were also used for the same purpose at St Vincents Hospital, Melbourne, before WWI. However, the technical properties of early X-ray machines meant that they only had an impact in treating cancer on or close to the skin. In December 1898, Pierre and Marie Curie announced the discovery of radium, and it was found possible to treat cancer at a deeper level by implanting radioactive material under the skin or within body cavities (brachytherapy). The immediate disadvantage of radium was that it proved enormously expensive and difficult to extract, and the first tiny amount was not imported into Australia until 1913, by which date small amounts of radium had also been mined in South Australia. The first radium department in Australia opened in 1913 at St Vincents Hospital, Sydney, where patients with skin cancer were given the new treatment. However, the pioneers of radiotherapy were in Paris, and Sydney surgeon Herbert

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Sally Wilde, The History of Surgery

Moran travelled there in 1922 to buy radium and observe the new techniques of implanting radium needles into the body. Radiotherapy in Queensland began with a Commonwealth grant in 1925 to the University of Queensland (which did not yet have a medical school) to set up a cancer research program. In 1927, the Commonwealth Government showed its faith in the new therapy by investing the large sum of 100,000 to buy 10g of radium. Under the constitution, health was a State and not a Commonwealth responsibility and accordingly the radium was to be divided up between the States as a part of a research program into cancer treatment, a small amount going to a single hospital in each State. In Queensland, the Mater Misericordiae Hospital in Brisbane was initially chosen and the Cancer Clinic there opened in 1928. While both the State and Federal Government contributed funds, most of the money was raised by the Queensland Cancer Committee. Unsurprisingly, the opening of the Cancer Clinic at the Mater was followed by much unhappiness at the rival Brisbane Hospital, and the Brisbane and South Coast Hospitals Board set up an X-ray therapy clinic there shortly afterwards. Both State and Commonwealth Governments supported the promise of a treatment that was believed to slow the growth of cancer, but not cure it altogether. In the 1930s, radium therapy epitomised the application of modern science to patient treatment. The Commonwealth Cancer Research Committee was set up in 1930 and appointments of radium registrars were made at a number of hospitals to facilitate the implementation of this scientific treatment. The treatment that Thomas Flynn received in 1930 was therefore both new and prestigious, but the Radium Registrar, Dr Uhr, and the Honorary Radiologist, Dr McDowall, had to negotiate their places in the hospital hierarchy with more established specialists such as the surgeons. Both were members of the Brisbane Hospitals Radium Committee, which discussed cases and monitored treatment, but so was surgeon Dr Meyers. Consequently, the radiologists did not enjoy the kind of autonomy in their clinical decision-making that surgeons took for granted. Consultation over cases and the scrutiny of results were built in to their work patterns. Consequently, for the first time in Australia, systematic assessment of the results of surgery compared to other forms of treatment became possible. According to the Report of the Royal Commission, on 26 September, Mr Flynns first operation was skilfully performed by Dr Meyers (of whose ability as a surgeon there is no doubt) in the presence of a number of surgeons who were Fellows of the Royal Australian [sic] College of Surgeons. The operation occupied about forty minutes, and was apparently completely successful. During the first operation on the right side of the neck, there was no problem with the anaesthesia, provided by Dr Beith. However, following a consultation between Drs McDowall and Meyers, it was decided that it would be best if Mr Flynn underwent a second operation on the left side of his neck, rather than being fitted with a radium collar. The second operation was performed on the 22 October, but this time the anaesthesia, delivered using the same intratracheal machine and tubes into Mr Flynns nostrils as on 26 September, proved fatal. Mr Flynn was anaesthetised by a Resident Medical Officer, under the supervision of Dr Reisz, but at some stage during the operation, Dr Reisz left the theatre and was not present to help the RMO when Mr Flynn got into trouble.

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In stark contrast to Mrs Canns case forty years earlier, in this instance the authorities were concerned to establish how and why Mr Flynn died, and to try and prevent any similar deaths in the future. This was a part of a long tradition of investigation into anaesthetic deaths, going back to at least the 1890s. Deaths under anaesthesia were routinely the subject of coronial inquests in both Britain and Australia and the substances used had changed considerably in the interim. Chloroform in particular acquired a bad reputation in the 1890s, and was largely replaced by ether and then a range of mixtures of substances, in sequence and in combination. In the 1920s and 1930s, many surgeons were favouring the use of local anaesthetics, even for major surgery, because of the lower risk of sudden heart failure. The injection of an anaesthetic into the spine made it possible to operate in the pelvic region, for instance, while the patient was still conscious. When Mr Flynn died, all of those present would have been very well aware of this background, and there is considerable evidence of a row between Dr Meyers and Dr Reisz. He thought she should not have left the theatre during the operation. It transpired that she had the permission of the Acting Superintendent of the Hospital to do so, but neither Dr Meyers nor the Royal Commissioner were happy with this. It is obvious [wrote the Commissioner] that a surgeon in charge of a serious operation should not be expected to have his attention distracted by having to worry about anaesthetisation, and I cannot emphasise too strongly that the person in charge of the anaesthetisation should not be authorised to exercise personal discretion as to leaving the operating room during the operation without the sanction of the surgeon in charge (and even without his knowledge as in this case). I understand that it is a general rule in operating rooms that the operating surgeon is supreme for the time being 129
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Dr Meyers, for his part, complained of the lack of discipline. The other element of this case that is in stark contrast to that of Mrs Cann, is the relationship between Mr Flynn, his relatives, and the other people involved. There was no attempt to in any way blame him for his own death, or to suggest that he was unclean or badly behaved, but when his relatives complained that he was coerced to return for the second operation, their word was given no weight. Mrs Flynn said that her husband had told one of the nurses that he was not coming back again and that the nurse had then said: We find ways and means of bringing you back if you do not come back, even if we have to ring up the Criminal Investigation Branch. However, Mrs Flynn could not identify which nurse this was, and despite having her story corroborated by her daughter, Mrs Brooks, when the hospital authorities denied that there had been any such coercion, their words were believed rather than those of the Flynns. I feel satisfied that Flynn underwent the treatment given to him at the Hospital, including the operations, willingly and without any protest on his part, wrote the Commissioner. Interestingly, the Commissioner took far more seriously Mrs Flynns complaint that her husband had not been told that the operation was serious. While he chose to believe the version of events recounted by Dr Uhr and Dr Meyers, rather than that recounted by Mrs Flynn, the Commissioner came to the conclusion that there was no evidence that Mr Flynn was told definitely by any person that either operation was serious, as undoubtedly each

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of them was. He believed that this was unsatisfactory and wrote that he was strongly of [the] opinion that there should be some definite rule at the Hospital that all patients about to undergo serious operations should be informed as to the probable seriousness of the operation130

Conclusion
Sarah Cann, who died in 1890, lived in a very different world from Thomas Flynn, who died in 1930. The inquiry into her death focussed on Mrs Cann herself and stigmatised her behaviour. In the process, the Brisbane Hospital absolved itself of any blame for the fact that she left hospital with a stinking wound and lice in her hair. The inquiry into Mr Flynns death, in contrast, was about the doctors: whether or not any of them had been negligent or incompetent in the application of scientific medicine to Mr Flynns case; whether discipline had been maintained in the operating theatre and whether the authority of the surgeon had been upheld. The complaints of Mr Flynns family were (politely) ruled as unfounded, but at the same time, the basic principle that patients should not only consent before they were operated upon, but also be told what it was they were consenting to, was reaffirmed. The autonomous, if unruly, patient had been transformed into the professionally treated clinical case.

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Chapter 4: Intermezzo, the Operations


This chapter discusses the operations themselves and asks exactly what kind of surgery was contributing to the enormous growth in this area of medicine. The answers are perhaps somewhat surprising. The growth of surgery was not simply a matter of more and more operations being performed increasingly often. While some procedures became particularly popular in the early years of the twentieth century, other operations fell out of fashion. It is also important to draw a distinction between well-established surgical procedures, whose performance had become routine, and new operations where there was not yet any consensus as to whether, when and how they should be performed. At the Melbourne Hospital, the number of operations listed in the Annual Reports increased from 1,770 in 1904 to 10,431 in 1934, an increase of almost 600% in 30 years.131 The Melbourne Hospital only treated adults, but St Vincents Hospital in Melbourne also treated children, and there the number of operations increased even more rapidly. There were just 538 operations in 1900, but the number grew more than tenfold over the next thirty years to 5,857, the figures at least partly inflated by the rapid growth in the number of children who were having their tonsils removed.132 For the period from 1900 to the early 1930s, most Australian public hospitals published some sort of information in their annual reports on the number and kind of operations performed. These detailed listings of surgery usually grouped operations by specialist category such as general surgery, gynaecology, eye surgery, and ear, nose and throat. However, there was no consistency between hospitals as to how they presented operative statistics, and there was no consistency between years as to how an individual hospital presented its operative statistics, and by the 1930s hospitals were beginning to grapple with the issue of what, exactly, constituted an operation. Several hospitals, including the Melbourne and St Vincents, ceased publishing any details about surgery from about 1933, and others such as the Hornsby and District Hospital in New South Wales, began to break the figures down into major and minor operations. Closer examination of the statistics gives a hint as to why this might have happened.133 At the Alfred Hospital, for instance, Melbournes third major general public hospital, the breakdown of figures indicates that less than 2/3 of the total number of operations were performed on in-patients.134 The rest were performed in out-patient and casualty clinics where the patient was sent home afterwards, rather than remaining in a hospital bed overnight. Some operations were considered so minor that they did not even involve the administration of an anaesthetic of any kind. Not only major abdominal surgery but also stitching up cuts and draining abscesses was adding to the rapid growth in the statistics, and at some hospitals even procedures such as taking blood from donors inflated the figures in the 1930s. In order to simplify the mass of data and identify the major trends, in what follows, surgical procedures have been divided into four different categories of intervention in the body, all of which were classified as surgical rather than medical. These categories cut across the conventional divisions between surgical specialties and they are: 1, removing matter out of

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place from the body; 2, repairing the body; 3, putting things in the body; and 4, removing body parts. Each of these four categories is associated with a different way of conceptualising the surgical task, and sorting early twentieth-century operations in this way helps to clarify some of the factors contributing to the growth in surgery.

1: Removing matter out of place from the body


The first category is removing things from the body which were classified as foreign objects or as matter which should not be there. These include bullets and foreign objects in the eye, for instance, but also parasites such as hydatids, stones in the urinary tract, some sorts of tumours or growths that were classified as innocent, and the pus in localised abscesses. Much of this kind of surgery has very ancient roots and, with the exception of the removal of hydatid cysts, parallels can be found in ancient and medieval surgical practice. There was some growth in these categories of surgery in the inter-war years, but not at a markedly greater rate than the increase in population. At both St Vincents and the Melbourne Hospitals, for instance, haemorrhoids, bladder and kidney stones and hydatid cysts continued to be removed in the 1920s and 1930s, but at the turn of the century none of these operations ever formed more than about 1% of the total volume of surgery, and by the 1930s their percentage contribution to the surgical workload had fallen to a fraction of that figure. This was not the kind of surgery that was driving the spectacular increase in surgical prestige and workload.

2: Repairing the body


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The second category is repairing parts of the body that were regarded as malfunctioning in some way, or having been broken by outside forces. This includes repairing fractures and sewing up cuts, but also repairing fistulae, in the anus, for instance, or in the vagina. It also includes repairing congenital deformities such as cleft palate, hair lip and imperforate anus. One of the most well-established and common procedures in this category in the early twentieth century was hernia repair. In 1910, hernia repairs made up about 15% of all operations at Kochers general surgical clinic in Berne, Switzerland, for instance.135 In Melbourne, hernia repair was also one of the most common general surgical procedures at the beginning of the century, although in general hospitals that also included ear nose and throat and gynaecology departments, it only made up between about 2 and 5% of all the operations performed, and its relative importance tended to decline during the period 18901940. In contrast, two other groups of operations to repair the body underwent considerable growth. Plastic surgery techniques increased in range and sophistication, especially skin grafting, and changes in the organisational structures within which the specialty of orthopaedic surgery developed were also associated with considerable growth. Railway and industrial accidents in the 1890s, the casualties of war between 1914 and 1918 and motor car and motor bike accidents in the 1920s and 1930s all contributed to the growing emphasis within orthopaedics on the rapid repair of fractures, rather than the long-term rehabilitation of those with rickets or osteomyelitis or tuberculosis.136

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Both category 1 (removing matter out of place) and category 2 (repairing the body) can be conceptualised as attempts to restore the body to normal functioning, to remake it in closer resemblance to an ideal picture of what a body should be like.

3: Putting things in the body


The third sorts of procedures which were categorised as surgical involved the insertion of instruments, objects and fluids into the body. Some were designed to cure, like the temporary radium implantations which became popular in the 1930s, or to relieve symptoms, such as the insertion of catheters in the bladder, and curettes, for removing matter from the uterus, while some were designed to diagnose, like the use of cystoscopes, for looking into the urethra and bladder and bronchoscopes for looking into the bronchial tubes. In the use of all of these instruments, the borderline between diagnosis and active intervention was not always clear, but I have chosen to emphasise the act of inserting an instrument into a body cavity. The instruments developed for these purposes were often the forerunners of later generations of instruments providing improved visualisation of spaces inside the body, including the bladder, uterus and intestinal tract, and operative access without open wounds. There was enormous growth in these sorts of interventions, not so much in the number of existing operations performed, such as dilatation and curette of the uterus, or D&C, but rather in the introduction of new operations. At St Vincents Hospital, Melbourne, there were 21 operations listed as curettage of the uterus in 1902, 177 in 1910, 150 dilatation and curette in 1920 and 107 in 1930. There was no steady pattern of growth and the procedure fell from about 4% of all operations at the hospital in 1902 (21/496) to less than 2% in 1930 (107/5857). However, the number of cystoscopies rose from none at the turn of the century to 93 in 1925 and 182 in 1930. At the Melbourne Hospital, too, D&Cs remained stable or even fell as a percentage of all operations, while cystoscopies first began to be performed in the 1910s, 55 were performed in 1920, 90 in 1925 and 317 (nearly 4% of all operations) in 1930. Meanwhile, in 1930, 411 Melbourne Hospital patients had radium implanted under their skin, an even newer and more rapidly growing procedure than cystoscopy.137 Besides radium implantations, other operations had a fleeting presence in hospital records. With the exception of the work of surgeons such as George Crile in the United States, blood transfusion did not become established as a regular procedure in civilian practice until after World War I. Saline injections were far more common in Australia. In the 1920s and 1930s, however, blood transfusions increased in frequency in association with changes in the technology of storing, treating and typing blood.138 Never-the-less, transfusions remained sufficiently uncommon for individual blood donations to be listed as separate surgical procedures at the Brisbane Hospital right up until the 1940s. Salvarsan or arsenobenzol injections were also initially counted as operations. Paul Ehrlich recommended Salvarsan for intravenous, rather than intramuscular, use. In the early twentieth century, this was not achieved by inserting a needle directly into a vein. Instead, a surgical procedure involving a skin incision, and sometimes also sutures, was performed, and patients were often hospitalised

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for a day or two following the injection.139 This procedure was performed by the hundreds in venereal disease clinics from 1914 onwards, inflating the operative statistics. The grand total of 688 Melbourne Hospital patients received the injection in 1920 (14% of all operations), before the procedure ceased to be classified as surgical and disappeared from the operative statistics. The category of inserting things into the body contains many new, high tech procedures, but most were categorised as minor surgery, or subsequently ceased to be categorised as an operation at all. Taken as a whole, these were the minimally invasive operative procedures of the 1920s and 1930s.

4: Removing body parts and performing ectomies


The fourth category of surgery was the removal of natural structures from the body that were diseased in some way and/or regarded as threatening the body as a whole. The earliest surgery of this type, and the stock in trade of surgeons for centuries, was amputations. By the inter-war years, amputations of major limbs were becoming far less common; the trend was to try and save limbs that had suffered compound fractures. But fingers were still amputated fairly frequently for various reasons, and as late as 1920, amputations made up about 1% of all operations at the Melbourne Hospital. However, the removal of parts of the body is the category of surgery most strongly associated with the growth in prestige of surgery as a whole. From the ovariotomies/oorphorectomies of the 1870s and 1880s, and the mastectomies and nephrectomies of the 1890s, to the hysterectomies and cholecystectomies of the early twentieth century, ectomies of various kinds were the epitome of major surgery. Abdominal surgery in particular was associated with high risk to the patient, high levels of difficulty for the surgeon and high rewards in both status and money for successful performance. Surgeons worked out how to remove ovaries, breasts, kidneys, uteri and gall bladders, but this depended on an understanding of anatomy and physiology that the body would continue to work (although in a modified way) without these structures. Sometimes, of course, it did not, and the fashion for total thyroidectomies was relatively short-lived. The two most commonly performed ectomies in the period between 1890 and 1940 were tonsillectomies and appendicectomies, and they have both had periods when they were fashionable and periods (since the 1950s in both cases) when they were much less commonly performed.140 However, appendicectomies grew from 23 (4% of all operations) at St Vincents, Melbourne, in 1902 to 325 (5% of all operations) in 1930, while operations to remove tonsils and/or adenoids grew from 102 (21% of all operations) in 1902 to 1,520 (26% of all operations) in 1930. Even in a hospital which did not treat children, the Melbourne, tonsillectomies as a percentage of all operations doubled in this period, while in a general hospital which treated children as well as adults, St Vincents, operations on the tonsils and adenoids accounted for one in five operations at the turn of the century and a staggering one in four by the 1930s. At the Mater Adults Hospital in Brisbane in 1932, the single most common operation was appendicectomy (360 cases or 13% of all operations) and the

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second most common was tonsillectomy (282 or 11% of all operations). However, in 1931 the Sisters of Mercy opened the Mater Childrens Hospital next door, and there 554 out of a grand total of 1,445 operations were to remove tonsils and adenoids, while the total number of patients admitted during the year was only 1,266. Some specialist childrens hospitals in this era could almost be called tonsillectomy hospitals. All of the surgical procedures that involve removing a natural bodily structure can be conceptualised as consciously constructing a new sort of surgically modified body. This is in contrast to categories 1 and 2, which were designed to restore/modify bodies to make them more like a normal model. The biggest growth area in major surgery in the period 1890 1940, that is to say, in surgery conducted under anaesthesia and involving admission as an in-patient if performed in hospital, was in ectomies, constructing bodies that were surgically modified in some way. This growth had two major components. The first was devising new operations to remove parts of the body, and during this fifty-year period many new ectomies were added to the surgical armamentarium, including cholecystectomies, prostatectomies and partial thyroidectomies. The second was performing any particular ectomy more often, and examples include mastectomies and hysterectomies, as well as appendicectomies. These two components of the growth of surgery represent different aspects of a process of social and technical change. The first, which might be described as inventing operations, represents a process of technological (and scientific and social) innovation. The second comes after the active phase of innovation, when closure or consensus about an operation has been reached. More and more surgeons learn how to perform the operation; elements of it become standardised; and if the condition for which it has been devised is both socially and clinically accepted as common, it might be performed very frequently indeed.
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Inventing operations, or operations as unstable objects


In order to understand the development of new operations, it might be helpful to think of surgery as technology, rather than science, and hospitals and operating theatres as workshops rather than laboratories.141 Certainly, this runs against the grain of the rhetoric that circulated within surgery. There was considerable discussion of science and self-conceptualisation as scientists, but discussion of technology was far less common and early twentieth-century surgeons did not generally regard themselves as engineers, let alone technicians. On the contrary, there was a whole tradition of surgical writing that set out to distance modern or scientific surgeons from the manual craft basis of what they were doing. But in the commonplace, everyday use of the word technology, surgery is precisely about the application of technology to the body. It is about using a variety of instruments and techniques to modify the body in some way, to re-engineer it, in order to repair it or make it work better. These techniques, these instruments, may be based on trial and error and experience, or they may be based on science, and the application of ideas from germ theory or anatomy or physiology represented the application of science to surgery. But surgery was still about technologies of the body, and the emphasis on experience and judgment in early twentieth-century surgery

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in addition to sciencewas essentially about the same sort of tacit knowledge as that built up over time and handed on from generation to generation by potters or farmers. Operations have careers, and the processes through which they are developed have many parallels to the processes through which other technological innovations are developed. Social and technological factors, as Wiebe Bijker has convincingly shown, are inextricably intertwined. A brief consideration of the history of a late nineteenth-century operation that has already been studied by a number of scholars illustrates some of the ways in which an operation may be socially, as well as scientifically or technologically, constructed. This example also illustrates how an operation may go out of fashion relatively rapidly as what is socially (as well as scientifically) accepted changes. Batteys operation, to remove normal ovaries, was never accepted by all gynaecologists or all patients, but it did enjoy a vogue with some in the United States, Britain and Europe for a decade or two, until in the 1890s the opposing voices began to outweigh those in favour.142 Removing diseased ovaries was controversial, but removing normal ovaries was even more so. Robert Battey, a surgeon from Georgia in the United States, devised the operation for women who consulted him because of amenorrhoea, but later extended the indications for surgery to include what he regarded as perturbations of the nervous and vascular system and general menstrual pain. He was proposing a solution to a problem, widely accepted by women as well as doctors in the 1860s, that conceptualised women as particularly subject to nervous disorders and painful symptoms associated with their reproductive system. Batteys idea was to remove both ovaries, bring on menopause, and thus restore the women to something more closely resembling the normal mental and physical state represented by men. Technically, once Battey changed his operative approach to the ovaries from through the vagina to through the abdomen, it was a perfectly reasonable operation, and death rates fell markedly in the 1880s, possibly at least partly because surgeons were becoming more experienced at operating in the abdomen. Finding (and removing) healthy ovaries may sometimes have been more difficult than finding diseased ovaries affected by large cysts, but the principles of operative exposure (working out where to make an incision to give the best access to the required area, with the least damage to surrounding structures) and ligating the ovarian pedicle, were the same whether or not the ovaries were diseased. Scientifically, the operation contributed to a new understanding of the role of the ovaries in menstruation and menopause, because after his first few cases Battey removed both ovaries, rather than just one, as was more common in the case of operating for ovarian cysts. However, as late as 1891, a leading gynaecologist could still express surprise that his bilateral oophorectomy patients all stopped menstruating. What led to the demise of Batteys operation were not any technical or scientific considerations, but a change in public opinion about how women should be treated, and in the balance of accepted beliefs about the role of the ovaries in their mental and physical health. More and more doctors expressed opposition to the operation, and increased the pressure to cease performing it. Meanwhile, as the century drew to a close and publicity surrounding falling birth rates rose, there was also a growth in pro-natalist sentiment. Removing both ovaries

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from relatively young women, thus unsexing them and potentially contributing to further falls in the birth rate, was becoming increasingly unacceptable, not only for the women and their families, but also for the wider public. Consequently, it was not just doctors, but also patients and members of the public, whose views had an impact on the demise of Batteys operation. It did not cease to be performed because of any perceived technical or scientific failings, but because of changing beliefs about womens bodies and attitudes to and by women. As Ornella Moscucci, Ann Dally, Ludmilla Jordanova and others have shown, the development of gynaecology in the nineteenth century was inextricably linked to the ideas that men had about womens bodies and that women had about themselves. But meanwhile, oophorectomy had helped to establish the specialty of gynaecology, and many doctors around the world had increased their familiarity with operating within the pelvis, especially the female pelvis.

The closure or stabilisation of an operation


In the nine years between 1901 and 1910, the number of operations performed at the Brisbane Hospital more than doubled, and the proportion of patients undergoing surgery rose from less than a quarter to more than a third of all admissions.143 Strikingly, by as early as 1906 a figure equivalent to more than 1% of the population of the greater Brisbane area was undergoing surgery in the Brisbane Hospital every year. And that was just surgery in one hospital. Operations were also performed in the Hospital for Sick Children, Brisbane, from at least 1888, and we have no figures on the number of operations performed at the various private hospitals and in patients own homes. However, the range of operations performed at the turn of the century was quite limited, and some of those most commonly performed were relatively low-risk minor procedures such as circumcisions, the removal of haemorrhoids and the excision of varicose veins. It is also as if the brakes were still on for two of the operations which contributed to the astonishing increase in the volume of surgery over the next twenty years. In 1900, both appendicectomies and tonsillectomies were performed in Brisbane, but not very often. Only five tonsillectomies are listed in the Annual Report of the Brisbane Hospital for 1901, and no appendicectomies. Just nine years later, Brisbane Hospitals surgeons had clearly developed confidence in the operations, and performed 60 appendicectomies and 78 tonsillectomies during 1910. The year 1900, therefore, offers a glimpse of the process of gaining confidence and experience in performing appendicectomies at Queenslands largest public hospital. At the time, of course, the surgeons concerned had no way of knowing that within a very few years this would become one of the most commonly performed operations, and it is clear from both published papers in the medical journals and unpublished case notes that in 1900 every possible case of appendicitis was accompanied by a struggle to decide whether or not, and when, to recommend surgery. The case of JD provides an example of this process.144 JD was a 34 year-old unmarried, Indianborn engineer. On Wednesday 21 February, he had shivering attacks off and on all day, followed by pains all over his body and especially on the right side of his abdomen. On Sunday 25 he began vomiting, and this was followed by diarrhoea, which ceased the day he

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finally went to the Brisbane Hospital. On Friday 2 March, he was admitted to Ward 1 under the management of Dr Thomson, with a high fever, pains in the abdomen and vomiting. Edinburgh-trained Dr Thomson was a very senior figure in the world of Queensland medicine. In 1899, he was President of the first Intercolonial Medical Congress of Australasia to be held in Brisbane. As he put it, Presidency of the congress was the very highest distinction which the Republic of Medicine can bestow on one of its subjects. Under Dr Thomsons instructions, JDs temperature was taken six times a day (twice a day at 6 a.m. and 6 p.m. was the normal Ward routine), ice bags were applied to the right side of his abdomen, and from Tuesday 6 March he began to receive daily enemas. On 8 March, Dr Thomson, the RMO, Dr Thomas, and the Medical Superintendent, Dr Mayne all saw the patient and discussed the case. They decided to operate and JD was prepared for surgery and taken to the Operating Room at 5.30p.m. However, he returned to the Ward less than an hour later without having had surgery. The case notes record that the operation was postponed, but are silent as to why this was done. The patient may have changed his mind about surgery; the light may not have been good enough to operate at that time on an early autumn evening; or Dr Thomson may have decided that it was in the patients best interest to postpone surgery until a later date. JDs temperature began to fall soon afterwards, and it continued to be recorded six times a day until 17 March, by which date it was nearly back to normal. The day after the postponed operation, the three doctors convened again at his bedside, and after that he was visited by one or other of the RMOs, Drs Thomas and Harding, several times a day. He also had regular visits from Dr Mayne, as well as less frequent visits from Dr Thomson. All were interested in the state of his abdomen. Day by day and night by night the nurses recorded that he was feeling increasingly comfortable, sleeping well and taking nourishment. By 29 March he is recorded as walking about; not complaining. He went home on 7 April, and the official verdict was: Appendicitis, relieved. At the turn of the century, appendicectomy was not a common operation in Australia, but it was the focus of considerable debate. It was the subject of one of the most lengthy discussions in the section of surgery at the 1899 Intercolonial Medical Congress presided over by Dr Thomson, and illustrates very well the way in which surgeons in Australia and New Zealand were influenced by ideas from both Britain and North America. Dr Charles Clubbe from Sydney gave a long paper outlining the current international view on the surgical treatment of perityphlitis, and this and the ensuing discussion underlined the wide range of opinions on the subject. Dr Clubbe argued that while the Americans tended to operate in almost every case and the English were very much more inclined to wait and see, and perhaps operate in the intervals between the attacks of acute appendicitis, Australians and New Zealanders should take a middle course. However, contributions from the floor indicated that the full spectrum of international opinion was represented in Australasia. English-trained Dr Hamilton Russell, one of the elite handful of Australasian surgeons at the time who held the Fellowship of the Royal College of Surgeons of England, agreed with the American view that removing an inflamed appendix was almost always the correct course of action. However, this depended on the availability of a suitably trained surgeon: If ever he was attacked with acute appendicitis, and he happened to be surrounded
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by skilful surgical friends, his appendix would be in a bottle within twenty-four hours. If he was in the country, however, where he could not get the advantages of such surgical aid, he would prefer the ministrations of his medical friends.145 Many country doctors, including Dr Doolan from Yass, Dr Bright from Hobart and Dr Scott from Ballarat, disagreed, and argued that surgery was by no means always the ideal treatment. Dr Thomson did not take a leading part in the discussion, but he highlighted the problems of diagnosis, arguing that appendicitis may not actually have been what ailed many of the patients who were told that was their problem. He also said that he was there to learn. A striking feature of this debate, given the popularity of the operation within a very few years, is how seldom any of these surgeons had removed an appendix. Dr Syme from Melbourne, for instance, another member of the elite little band holding an FRCS, referred to operating just twelve times to remove an appendix.. Dr Clubbes paper referred to 347 cases treated, presumably by all the surgeons, at the Prince Alfred and Sydney Hospitals in the previous six years. However, it seems that the appendix was only removed from 88 of these patients, an average of just over 7 appendicectomies per hospital per year, with 33 deaths. Another 24 patients died without any surgery. Even R. A. Stirling, another of Melbournes most prominent surgeons, did not report removing any appendices during six months work at the Melbourne Hospital in 1897, and in a lecture to medical students he reported two patients whose appendix he couldnt find on operation, one of whom died. In August 1898 he said that in his career to date he had performed forty-two appendicectomies in acute cases, with twelve deaths.146 Henry OHaras RMO, Dr Vance, thought it worthwhile to report that Mr OHara treated five cases in three months of 1897 at the Alfred Hospital in Melbourne, with no deaths.147 The experience of country surgeons was likely to be very limited by comparison. In 1898, W. J. Long of Bendigo, Victoria, reported three cases, in one of which he couldnt find the appendix, but all three survived.148 As has already been noted, no appendicectomies were performed at the Brisbane Hospital in 1901, but in 1902, there were six appendicectomies, with three deaths. Clearly, at the turn of the century this was both a high risk procedure and one that was relatively infrequently performed. In June 1902, Sir Frederick Treves performed an operation at Buckingham Palace. The patient was Edward VII, and the operation famously delayed his Coronation.149 This event has often been associated with the subsequent popularity of appendicectomy among both surgeons and patients. However, the story is not quite that tidy. Treves was famous for performing appendicectomies, but he was particularly known for delaying surgery when there was high fever. He preferred to wait until the crisis had passed. In Melbourne, George Syme also advocated operating in the intervals between attacks of appendicitis and Dr Thomson and his colleagues may have decided to follow the same strategy in the case of JD at the Brisbane Hospital. Further, in June 1902 Treves did not remove the royal appendix; he drained an appendiceal abscess, and only after consultation with several other eminent authorities (including Lord Lister), and delay in agreeing on surgery from both the doctors and the patient.150 Never the less, this operation took place at the same time as surgeons in Britain and Australia were coming to agree with their American colleagues on the best course of

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action for suspected appendicitis. In 1897, even experienced and confident surgeons like R. A. Stirling in Melbourne might be inclined to wait and see when faced with symptoms of appendicitis, but within five years the accepted wisdom had changed to agree with Hamilton Russell, that an operation should be performed by a skilled surgeon (not a general practitioner) without delay. The publicity associated with Edward VIIs surgery may have contributed to changing the publics view of surgery in general and surgery for appendicitis in particular. But around 1900, the prestige of surgery was rising for other reasons. According to the Right Reverend J. F. Stretch, Bishop of Brisbane, in his opening sermon before the Brisbane Intercolonial Medical Congress of Australasia in 1899, surgery could be divided as before Lister and after Lister. 151 Public confidence that Listers methods had made surgery safe may well have outrun actual surgical results, especially in Britain and the patriotic antipodean colonies. After all, Lister was one of their own. By 1900, the stock landmarks along the road to the wonderful heights achieved by late Victorian medicine were anaesthesia and antiseptic/ aseptic surgery, but as Dr Thomson put it in his presidential address: If we have to divide the anaesthetic honours with our American cousins, we can safely assert that the greatest discovery of any or all time affecting surgery was made by the Englishman, Joseph Lister. Lister was elevated to the House of Lords in 1897, and the chests of surgeons everywhere in the Empire swelled with reflected pride. Both Queen Victoria and her son Edward, it would seem, had confidence in surgery. It would not be surprising if a little of that confidence came to be shared by members of the public. In 1900, the treatment of appendicitis was still going through a process of active innovation as doctors debated whether surgical treatment was appropriate, when to operate and which operation to perform. The decision-making processes were relatively complex, but also somewhat confusing for patients and their friends. Partly as a result of this, one of the important shifts that was associated with the treatment of appendicitis was that patients, especially public hospital patients, increasingly often tacitly agreed to the black boxing of the decision, and handed it over to the surgeon. Whether, when and how to operate might well be a matter of life and death, but there was increasing acceptance that this was a part of the legitimate complexity of medicine, that patients were not in a position to make informed decisions about the matter, and that they should take their doctors advice. By 1920 closure on the treatment of appendicitis had been reached amongst doctors, as most came to agree that early operative intervention carried the lowest risks, and meanwhile the relevant social group influencing the modes of treatment had effectively shrunk from doctors and patients, to just doctors. By the 1920s, most medical students watched appendicectomies performed, and went out into the world as new doctors trained to recommend early operative intervention to patients with lower right abdominal pain. In 1900, the surgical treatment of appendicitis was controversial in Australia, some general surgeons performing it often and others hardly ever. Twenty years later operative treatment of appendicitis had ceased to be controversial and hundreds of appendicectomies were performed every year at all major hospitals. However, the standardisation of the operation should not be over-emphasised. In

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1933, for instance, one of the surgeons at the Royal Prince Alfred Hospital in Sydney could still write that: abscess around an appendix is dealt with at the Royal Prince Alfred Hospital in a surprisingly varied manner. 152 Ulrich Trhler studied the proceedings of the Swiss Society of Surgery between 1913 and 1988 and found that there, too, the treatment of acute appendicitis ceased to be controversial at the beginning of his period. The Swiss Society of Surgery scheduled the topic as a special theme for the last time in 1913.153 The operation had stabilised and was becoming so routine that it was often performed by general practitioners. In the 1930s, the operation became controversial once more, as death rates rose and there was an argument amongst doctors as to whether appendicectomy should only be performed by full time surgeons. GPs, it was argued, had higher death rates and performed the operation inappropriately.

The rise and fall of tonsillectomy


The other crucial operation for the growth of surgery in the inter-war years was the removal of tonsils and adenoids. Like appendicectomy, there was a prolonged period of debate about the indications for operation. In 1886, for instance, one popular text book of surgery argued that: The occurrence of tonsillitis, especially in the follicular form, should always lead to a careful examination of the drainage of the house in which the patient resides, or of that in which he is occupied during hours of business. Should this be defective, the treatment of the symptoms will be of little service until the source of the danger is removed.154
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In contrast, in his Manual of Surgery published in 1888, Frederick Treves argued that hypertrophy of the tonsils often necessitates operative interference. 155 However, unlike appendicectomy, the death rate, with or without surgery, was very low. Importantly, this was an operation most commonly performed on children. The combination of these two characteristicslow risks and decision-makers (parents) particularly susceptible to pressure to agree to a procedure argued to be in the best interests of the childsaw tonsillectomy enjoy a period of quite stunning success, generally in conjunction with the removal of the adenoids. By 1921, the tenth edition of Rose and Carless, one of the most widely used surgical text books in Britain and Australia, was emphasising the dangers to children of mouth-breathing. This volume featured pictures of children with what were described as adenoid facies.156 One illustration was said to show: well the sleepy look, the pinched nostrils, the open mouth and projecting upper central incisors, so characteristic of this condition. Another view of a child with neglected adenoids was described as showing that the chest is shallow and retracted, and the spine kyphotic. The undesirability of these symptoms was underlined by the social characterisation of the sufferers: Enlarged tonsils and adenoids are usually seen in children of the poorer classes who live in small homes in a large city. They are constantly found associated

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with enlargement of the cervical lymphatic glands, phlyctenules of the cornea, and running noses due to constant repeated colds which result in excoriation of the nostrils. These children live in unhygienic surroundings, are fed generally on carbohydrate diet, and are usually the subjects of pediculus capitis. The condition is much less frequently found in the well-cared-for children of the better classes157 Tonsillitis was also implicated as a possible cause of both appendicitis and rheumatism and so it is possibly not surprising that in 1938, one British ENT surgeon described the rapid rise in the incidence of tonsillectomy after about 1903 as one of the major phenomena of modern surgery, and stated that 200,000 a year were performed in the UK alone, claiming that it had become the commonest surgical operation.158 However, by the 1930s, at least some doctors were beginning to challenge the widespread removal of tonsils and adenoids. In England in 1938, Dr James Glover published the results of his study of geographical variations in tonsillectomy rates in the Proceedings of the Royal Society of Medicine.159 Concerned at the high rates of tonsillectomies performed by some of his colleagues, he conducted a study of school children and found tenfold variations in the rates across some counties.160 Other studies since have confirmed the particular variability in tonsillectomy rates, both with and without the removal of adenoids.161 In the 1950s, the popularity of the operation began to decline, but in 1977 it was described as still the most common surgical procedure performed in the United States and Canada and the main reason for the hospitalization of children. A study of tonsillectomies and adenoidectomies in the State of Vermont in the early 1970s found that the rate varied from 4/1000 children at one hospital to 41/1000 at another and that just ten out of a total of 92 doctors performing the operation were responsible for half of all the tonsillectomies in the State. The authors came to the conclusion that these communities were so similar in their demographic characteristics and pattern of medical insurance (itself an important contributor to variations in rates of surgery), that the variation was almost certainly due to what they called variation in physician attitudes. Partly as a result of studies of this kind, as well as changes in ideas about auto-infection and the possible association between tonsillitis, appendicitis and rheumatism, the numbers of tonsillectomies performed were falling rapidly in most countries by the 1970s. Tonsillectomy, with or without adenoidectomy, might fairly lay claim to being the quintessential twentieth century operation, like limb amputations in the nineteenth century or phlebotomy in the eighteenth. While heart transplants may have wowed the media and created surgical superstars, at its peak in the middle decades of the century, tonsillectomy was the common or garden surgical experience of something close to half of the population certainly in North America and Europe. Gerald Grob has argued that for most of the twentieth century, tonsillectomy was the most commonly performed operation in the US and although it never seems to have been quite as common elsewhere, it was (and in many places still is, although under challenge from myringotomy) the most commonly performed

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operation among children.162 A sampling of New York City school children in the 1930s found that fully 61% no longer had their tonsils. A more modest estimate from the 1950s found that about 1.5 million tonsillectomies a year were being performed in the US and that some 40% of Americans were tonsil-less. Members of the higher socio-economic groups seem to have been particularly prone to losing their tonsils and adenoids and in England, Glover found that fully 83% of new Eton entrants in 1938 had undergone tonsillectomy.163 From at least the 1970s, a range of studies have attempted to refine the indications for surgery, including tonsillectomy, in an attempt to achieve more consistency in surgical rates. In 1976, for example, Gladstone R Osborn, a pathologist, and Noel Roydhouse, a New Zealand ENT surgeon, published The Tonsillitis Habit.164 As DFN Harrison, Professor of Laryngology & Otology at the University of London, pointed out in his foreword to the book, parents receive conflicting and confusing advice from everybody and the final decision about surgery relates more to where you live and how much you can pay than to the application of a precise set of clinical standards, a lament that could apply to many operations besides tonsillectomy.165 By the 1960s, tonsillectomy rates were falling around the world, even though the actual rate varied substantially from country to country, and these falls continued into the 1980s. In 1974, for instance, the rate of tonsillectomy and adenoidectomy (T&A) in the Netherlands was close to 300 per 10,000 children. By 1985, this had fallen to about 100 per 10,000 children. In Britain, in contrast, starting from a much lower figure, the rate of T&As fell from about 80/10,000 children in 1974 to about 50 in the 1980s. In 1986, crude Australian tonsillectomy rates were down to 1.73/1000 from somewhere around 5/1000 ten years earlier. This compared to about 0.6/1000 for Japan and 1.9 for the UK. By 2001, the Australian tonsillectomy rate had risen again (in line with international trends) to around 2.5/1000 population, but this was still only about half the rates that had prevailed a quarter of a century earlier. Tonsillectomy rates fell between the 1950s and the 1980s because some surgeons thought they were too high, and in an international debate conducted through conferences, journals and peer pressure, their view prevailed. Recent much smaller rises appear to be associated with new linkages found between enlarged tonsils and adenoids and sleep problems, rather than with any changes in the underlying epidemiology, although there have been some suggestions that fewer tonsillectomies in childhood have been followed by more tonsillectomies in adolescents. But the general consensus of clinical opinion about the indications for tonsillectomy has quite clearly changed over time. This is a bread and butter operation that has been frequently performed for more than a hundred years, but with dramatic shifts over time in views as to when and why it should be performed. ENT surgeons quite legitimately differ in how they assess whether or not children need this particular operation, and this is unlikely to change. In 1976, Michael Bloor examined the differences between ENT specialists in the way that they assessed patients for tonsillectomy and came to the conclusion that: variation in medical assessments is a natural concomitant of the structure of medical knowledge.166 This insight has been developed further by Catherine Pope in her recent work on the role of

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contingency in contributing to legitimate variations from evidence-based norms in surgery.167 In addition, the last twenty years or so have seen the rise (once more) to importance of an additional reason why rates of surgery vary from some notional norm: patient choice. Parents are playing an increasing role in decision-making about tonsillectomy. As one English commentator put it in 2003: Is tonsillectomy back in fashion? Part perhaps of the present day enthusiasm for all things retro-chic. appropriately counselled parents can make a decision with and on behalf of their own child. Many of them elect for surgery. But we should not delude ourselves that this decision is made on the basis of anything they have been told during the counselling process. the word on the street is still this if you are having trouble with your throat, you should have your tonsils out. Fashions may change capriciously; tenets in popular culture are harder to dispel.168 Tonsillectomy is an elective operation that is perceived to carry only minor morbidity and low risks of complications. It could be argued that it is therefore particularly appropriate that parents and children become actively involved in informed decision-making about any such surgery. In the seventy years since Glovers study, tonsillectomy has become a much less common operation, but it is still the operation most commonly performed on children, and the variability in rates between countries and within countries remains a marked feature of the epidemiology of the procedure.169

Production line operations vs. unstable objects


Between 1890 and 1940, surgery as a field increased enormously in complexity at the same time as the number of operations was growing. A five or even tenfold increase in the number of operations performed at a particular hospital was accompanied by changes in the way that the work was organised. Specialisation was one of the first results, and the division of labour between junior and senior surgeons was another. Minor procedures were performed in outpatient clinics under local anaesthetic, or no anaesthetic at all, by junior doctors, under the supervision of the honorary surgeons to out-patients. Salvarsan injections were given in venereal disease clinics; tonsillectomies were performed in ENT clinics; simple fractures were put in plaster in fracture clinics. Some of these procedures, especially tonsillectomies, were performed literally hundreds of times a week in major public hospitals, particularly in hospitals that specialised in treating children. It is hard to avoid the conclusion that something resembling a production line was involved as large numbers of children and their parents were shuffled through out-patient waiting rooms, to the surgeons chair, through a recovery room and back into the outside world. But the removal of tonsils and adenoids, like any operation that was performed many hundreds of times in any one hospital, was a stable operation, a technological innovation that had reached closure. Debate over when and why and how it should be performed had fallen to a low level in the medical journals in the 1920s, while new doctors learned how to perform it in a routine, standard fashion. This
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might vary from hospital to hospital, depending on the views of the senior ENT surgeon, but within hospitals it had ceased to vary very much from patient to patient, and the task was often, if not always, delegated to relatively junior doctors. At the Childrens Hospital in Melbourne it was even performed by medical students. However, there was a very great difference between operations like this, stable production line operations, and the new ectomies being developed all the time by surgeons to inpatients. At the Alfred Hospital in Melbourne in 1931, for instance, more than a thousand ENT operations (mainly the removal of tonsils and adenoids) were performed in out-patient clinics, and a further 289 were treated as in-patients (probably because of post-operative haemorrhage). None of these patients died. In contrast, in the same year at the same hospital just six patients underwent a prostatectomy and four of them died. While tonsillectomy is the prime example of a stable (and fashionable) operation in the 1930s, removing the prostate is a good example of an unstable operation, still going through a process of innovation. There was enormous debate about it in the medical press and no consensus as to when and how it should be performed, and we can be almost certain that its performance was never delegated to junior surgeons in this era. Similarly, the early attempts at surgery on the brain in Australia were rapidly followed by an acknowledgment that this should be the province not merely of full time surgeons, but of people who had chosen to sub-specialise and call themselves neurosurgeons. The death rates were terrifying, and brain surgery became associated with a high degree of specialisation. Geoffrey Kaye noted a death rate of 28.6% for 63 patients who underwent neurosurgery at the Alfred Hospital in Melbourne between 1934 and 1936.170 In 1937, Leonard Lindon reported a death rate of more than 50% for 94 patients operated on in Adelaide. He called for a special clinic with a pathologist, an exclusive theatre team and their own operating theatre to help reduce these appalling mortality figures.171 Not only the surgeons, but also the anaesthetists and the nurses developed particular expertise and worked with newly devised instruments in specially equipped operating theatres. While they struggled to devise techniquesfor keeping the patients head still, for instancewhich helped to improve the reliability of results, there was nothing routine or standard about brain surgery in the 1930s.172 As has been noted, in 1900 appendicectomy was not yet a stable operation as the standard treatment for an inflamed appendix, while thyroidectomies, hysterectomies and cholecystectomies also went through lengthy periods when there was no agreement about whether, when or how they should be performed. Other operations also went through periods when they were fashionable, and periods when they were not. As we have seen, Batteys operation for removing both ovaries to bring on menopause in women, especially those in mental institutions, was already going out of fashion before his death in 1895. Nephropexy, an operation to fix so-called movable kidneys, enjoyed a considerable vogue after it was first popularised by George Edebohls in New York from 1893.173 Edebohls operation might almost be considered to have taken over where Batteys operation left off, as a treatment for neurasthenia, especially in women. In the United States before World War I, surgeons as famous and respected as William Mayo and Howard Kelly published hundreds of cases of treatment of floating kidneys by a range of methods of surgical fixation.

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Nephropexy continued to appear occasionally in Australian surgical records throughout the 1920s. However, as in the case of Batteys operation, some surgeons were highly critical of the procedure, including the influential urologist William Braasch of the Mayo Clinic, and the operation had more or less gone out of fashion by the 1940s. Similarly, surgery for constipation was a fashion that came and went. It is largely associated with the London surgeon Arbuthnot Lane, and he travelled to the United States in 1909 to demonstrate his procedure for removing all or part of the colon. Various American surgeons tried the procedure for a while and Brisbane surgeon Lillian Cooper travelled to London to watch Lane at work and learn how to perform an operation for what was described as chronic intestinal stasis. As in the case of Batteys operation and nephropexy, the conceptualisation of the disease and the associated explanation of diverse groups of symptoms have since changed, and Lanes operation is no longer performed. In contrast to operations such as this which have been discarded altogether, tonsillectomies and appendicectomies are still frequently performed, but not nearly as frequently as in the 1920s. Annmarie Adams and Thomas Schlich have discussed the associations between surgery and science and described the post-Second World War operating room as a space of experimental science.174 They argue that the laboratory revolution in medicine and the rise of surgery occurred at the same time in the late nineteenth century and that new operations such as tonsillectomy and appendicectomy were regarded as based on science. The essence of surgery they wrote, is to subject the living material of the patients body to the surgeons will and they argue that this required controlled laboratory-like conditions. Over time, many operations did indeed come to be performed in more or less controlled, standard ways that were regarded as scientific, and had generally predictable outcomes. As has already been noted, despite the persistence of complications such as post-operative haemorrhage, tonsillectomy is an obvious example. Operations such as this came to be considered minor and straightforward, and were often performed by junior trainee surgeons. But elsewhere in the same hospitals where such production line operations were being performed, other operations were far from standardized, and surgeons were often notably failing to subject the patients body to their will.

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Part 2: Surgeons
The three chapters in Part 2 shift the focus of attention from the patient to the surgeon, showing surgeons in their social context and not just as disembodied intellects. Surgeons are, like everyone else, fallible human beings, gendered and embodied themselves, just like their patients. They have home lives and social lives, as well as surgical careers. In Part 2, questions are asked about the culture within which so much technological and scientific innovation took place in the early twentieth century, in an attempt to understand why so many people were prepared to trust surgeons so much for so long.

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Chapter 5: Achieving Distinction


In theory, all doctors were entitled to perform surgery as a part of their medical practice, and many general practitioners built up an interest in surgery, moving from minor operations to more major procedures as they acquired experience and confidence.175 Until after World War II, a large proportion of surgery in rural areas continued to be performed by general practitioners. However, from at least the 1890s, major surgery such as abdominal operations was increasingly the province of specialists and in urban areas, an increasing proportion of surgery was performed by specialist doctors who did little else. In Australia and New Zealand, as in Britain, the emergence of full-time surgeons and other specialists depended on a network of general practitioners who were prepared to refer patients for specialist treatment. Urban specialists therefore needed to build their reputations with general practitioners just as much as with their patients. In rural areas, however, those who performed surgery depended very much more directly on the good opinion of their patients. Accordingly, the first part of this chapter outlines the differences between the practice of surgery in rural and in urban areas, whilst examining the ways in which surgeons built their careers and acquired distinction. The second part of the chapter goes on to describe the characteristics of a range of surgical lifestyles in the interwar years and outlines some of the ways in which home and social life could be seamlessly integrated to support the reputations of successful surgeons as trustworthy experts.

Trust and the moral economy of surgery


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During the 1920s and 1930s, surgery shared in the public confidence in the efficacy of scientific medicine and the good intentions of its practitioners. This level of trust in medical practitioners is in marked contrast to attitudes to drug manufacturers.176 Harry Marks has shown how regulations and restrictions on the introduction of new drugs in America from the late 1930s were linked to widespread suspicion of commercial motives, and similar attitudes to drug companies prevailed in Australia and New Zealand.177 However, the motives of surgeons were not suspected in the same way, and surgery was not subjected to the sort of tests of safety and efficacy that were beginning to be applied to drugs. Surgeons were free to adopt, adapt, or invent any surgical procedure as they saw fit. Between the 1880s and the 1940s there was an enormous increase in the range of surgical procedures and the number of surgical patients, but before the 1950s there was seldom good evidence as to whether or not operations worked or were safe.178 Patients, therefore, had to make a leap of faith in agreeing to submit to them. They had to trust the surgeon, and this trust has three major components: 1: trust in the efficacy and safety of the treatment; 2: trust in the technical competence of the medical practitioner; 3: trust that the medical practitioner will act in the best interest of the patient.

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As was shown in chapter 1, late nineteenth century surgeons had to win the trust of their patients, whose confidence in, and consent to, surgery could not be taken for granted. All three of the components of trust were open to question. Surgeons had to talk to their patients and persuade them to agree that surgery was in their best interests. In the early twentieth century, that pattern of behaviour changed significantly. The hospitalisation of surgery was associated with a progressive decline in patient autonomy, and at the same time, the authority of surgeons rose. They were increasingly professional, and they were increasingly confident in the appropriateness and efficacy of their modes of treatment. Quite possibly they were also becoming more competent. They were certainly becoming more experienced. But most importantly, they were increasingly trusted to act in the best interests of their patients. Effectively, many patients withdrew from an active role in decision-making about their own treatment, especially in urban areas where they were referred to a specialist surgeon by their general practitioner. As we saw in the case of Thomas Flynn, sometimes patients may have been manipulated or even coerced to agree to the recommendations of experts, but the structures within which doctors and others were allowed to exercise such power also reflect rising levels of societal trust in the benevolent use of medical expertise. Those people who built up referral practices as full-time surgeons were necessarily acknowledged by their peers as having special expertise. Sometimes such a reputation was simply acquired through experience, but doctors who were particularly interested in surgery had a number of other options for raising their profile and achieving distinction among their peers. Some doctors became surgeons gradually over time, giving up their general practice bit by bit as their surgical workload increased. But by the turn of the twentieth century young doctors increasingly frequently deliberately planned surgical careers for themselves, and an important component of such a career was to obtain a public hospital position as honorary surgeon to in-patients. Such positions, especially at the major teaching hospitals, carried with them considerable prestige, and it was perceived to be easier to build up a large (and lucrative) private practice from such a base than from private practice without a hospital appointment. Partly, this was because such appointments implied peer endorsement of competence; partly such appointments placed surgeons in the position of teaching surgery to medical students and young doctors, and hence building up a network of general practitioners who knew them personally. But an important feature of honorary public hospital appointments was that they were honorary; those who held them worked for free. This conferred on them the status and trust that went with such honourable behaviour. Recently, a Professor of Population Health was quoted as saying that people are rarely in medicine primarily for monetary gain.179 There is a long and complex tradition behind beliefs of this kind about medicine.180 From its beginnings in the mid-nineteenth century, for instance, the British Medical Association frowned upon advertising by its members. But by the early twentieth century, professionalisation within medicine was associated with broader conceptions of appropriately moral behaviour. Medical practitioners were not expected to engage in the exclusive pursuit of economic self-interest. In meeting this objective, doctors who performed unpaid work in public hospitals had an advantage over doctors who worked entirely in private practice. There may inherently have been less suspicion of their commercial motives and more trust in their benevolent intent, because they devoted a highly

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visible part of their time to this honorary work. Effectively, specialist surgeons with public hospital appointments worked within a moral economy.181 They were subject to a complex set of relationships and expectations where social obligations and group understandings of right and wrong influenced both individual and group behaviour. Consequently, their work was not driven exclusively by the logic of market forces.182 This is in contrast to the ideas surrounding the justification for the pursuit of individual economic self-interest, which dominate early twenty-first century understandings of the phrase market economy.183 During the twentieth century, there were two major political approaches to health care in Australia. On one side there were those who favoured a mix of charitable provision for the poor and private provision for the rest, with or without varying methods of voluntary insurance. On the other side, there were those who favoured government provision for all with the option of private provision for those who were prepared to pay extra.184 With the benefit of hindsight, an interesting feature of the many heated debates on these issues over a long period of time was the assumption by all parties that health care provision for the poor should not be left to market forces. In this sense, throughout the twentieth century the provision of health care in Australia (as in New Zealand, Britain and Canada) was influenced by concepts appropriate to a moral economy, as well as by commercial considerations.185 Whilst some of those who worked in this industry, including doctors and nurses, were expected to consider their patients first and their pockets second, it was widely assumed that others (such as drug companies), would be driven more exclusively by the profit motive. Among the benefits to surgeons of taking up honorary appointments and working within this moral economy was a growing level of trust in their benevolent intent. But in order to succeed, surgeons had to build a reputation as not only trustworthy but also expert.
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In the early twentieth century, almost no formal training in surgery was available in Australia or New Zealand. Expertise was generally acquired as the result of self-directed learning by individual doctors and there were a number of ways in which they could build reputations as more knowledgeable and experienced than their general practitioners colleagues. They could travel overseas and spend time watching famous surgeons there; they could give papers at medical conferences in Australia or New Zealand; they could publish papers in the Australasian medical journals; and they could take additional specialist qualifications. Until after World War II, such postgraduate qualifications were usually obtained in Britain. In particular, the Fellowships of the Royal Colleges of Surgeons of England and Edinburgh and, to a lesser extent, Ireland, were the benchmark surgical qualifications in Australia and New Zealand until at least the 1950s. Australasian surgeons were influenced by both British and North American surgery, and many of them travelled to see for themselves the new procedures that were being developed. In the 1920s, it was quite common for Australian and New Zealand surgeons to make round the world study tours, visiting operating theatres in North America as well as Britain. Consequently, as was noted in the introduction, by World War II, the average surgeon in Australia or New Zealand was likely to be just as well informed about developments in his or her specialty in the United States as about developments in the United Kingdom. However, this mainly applied to full-time specialist surgeons in urban areas. Rural practitioners had to find other ways to build their reputations.

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Surgery in rural areas


Surgery could bring in valuable extra income for a doctor who was struggling to make ends meet, but surgery only gave a practitioner an edge over his or her competitors if the operations not only went well, but were known to have gone well, thus enhancing the doctors reputation. In this context, advertising was important, and doctors had two different audiences for their behaviour: their patients and their colleagues. Advertising to patients or the public was seriously frowned upon, and later expressly prohibited, by the codes of conduct of the British Medical Association. According to an 1895 editorial in the official journal of its Australasian branches, any advertising beyond an announcement of change of address or commencement or resumption of practice reduced members to the level of quacks and charlatans, although some allowance could be made for doctors in rural areas.186 In practice however, doctors did advertise, but usually indirectly. Whilst specialists generally advertised to their colleagues in one way or another, general practitioners needed to make themselves known to their patients, and this is well illustrated by the career of Dr Billy Little. Dr Little, who lived in Warracknabeal in the wheat growing area of northwest Victoria, has left us the story of his early years in practice through a series of letters that he wrote home to the woman he may have wished to marry, one of Canadas first women doctors.187 Dr Little did his initial training in Canada, before travelling to Edinburgh for further experience and qualifications, and then migrating to Australia. He had never practised as a doctor before arriving in Victoria, and his letters are full of references to the ways in which he thought his behaviour might influence what his private patients thought of him. I am only on trial, as it were, he wrote. People look and wonder whether to trust me or not. Once a name is made everything goes smoothly. He was very much aware of the importance of his reputation for his success in practice, and that surgery carried particularly high risks for his good name. It is a very easy matter to cover up any mistakes in practice of medicine, he wrote, but it cant be so easily done in surgery. But he was more than happy to take the risk and his letters indicate that in his first year of practice in 1890, he tapped patients for hydatids and for empyema (a collection of pus in the lung), as well as performing tonsillectomies, tracheotomies for diphtheria and at least one craniotomy. It is clear that he was performing most or even all of these operations for the first time. I cut a young mans tonsils off abt. a month ago. He had been doctoring for yrs. with sore throat. As soon as I examined him I told him they would have to come off, to which he agreed. I sent away for a Tonsilatome [tonsillotome], cut them off and charged him $15 for the job. His throat is cured.188 Operations were newsworthy, and major surgery in particular was often reported in the local newspapers. Dr Little was also keen to have news of his successes passed on through less formal networks of patients and their friends. After performing a craniotomy, for instance, he wrote: The woman is making a good recovery and is a good advertisement for me. Surgical operations in rural areas were routinely performed by general practitioners who, of necessity, dealt with the full spectrum of medical practice. Specialist surgeons in the cities

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argued that their rural colleagues were consequently jacks of all trades, and masters of none, and there may well have been some justification for this accusation. But Australian and New Zealand surgeons, including some GP surgeons in rural areas, did develop special expertise in one particular form of surgery. In 1898, Dr Ritchie published a paper concerning five cases of hydatids in the Wimmera area of western Victoria in the Intercolonial Medical Journal of Australasia. Hydatid cysts, a stage in the complex multi-host life cycle of a tape worm, were particularly prevalent in humans in South Australia, Victoria and New South Wales. Robert Ritchie attributed this not only to the close relationships between men and their dogs (the principal host for the worm stage of the parasite), but also to the lack of rapidly flowing water, so that hydatid eggs once discharged into a stream or dam were not washed away. practically all the Wimmera water supply, once it has become contaminated, remains so during the life of the ova Another factor of some importance is the great heat of the summer, which causes those working in the fields to be glad to relieve their thirst anywhere.189 The two main treatments for hydatids at the time were tapping, that is making a small incision, inserting some sort of tube or suction device and draining the cyst in which the parasite was living, or making a larger wound in order to empty the whole cyst. Either procedure might be attended by complications of one sort or another. It might be difficult or impossible to find the cyst; there might be one or more daughter cysts; a cyst might burst, releasing its contents into other spaces within the body and, in any case, the wound might become infected. So why did patients agree to submit to these procedures? The answer is that patients and/or their friends did not always agree to submit. Their agreement depended on their relationship with the doctor who was urging the surgery, and that, in turn, could depend on a complex set of factors. His parents were unwilling to allow surgical interference, wrote Dr Ritchie of an eight year-old boy who he had diagnosed with hydatids, but were at last prevailed upon. Clearly, the persuasiveness of the doctor was an issue, and that, in turn, might depend on how certain he was himself that this was the best course of action, and that he was competent to carry it out. Dr Ritchie was prepared to indicate in print to an audience of his colleagues that he sometimes had doubts about whether or not to operate, and which operation to perform: After much hesitation, he wrote, of a 28 year-old man who was personally convinced that he had hydatids, I needled the left base, and, after several insertions, drew off clear hydatid fluid This patient had hydatids in his lung, so that surgery to remove the cyst was a relatively difficult procedure, involving the excision of two inches of the ninth rib. Dr Ritchie described the hydatid cyst as: about the size of an emus egg. This was removed and a drainage tube inserted. He took the chloroform very well The surgery was performed in the Horsham Hospital, where the patient remained for some time because he contracted a post-operative erysipelas infection. The acceptance of germ theory and the adoption of some version of aseptic operating techniques did not mean an end to post-operative wound infection. What it did mean, however, was that post-operative infection was no longer taken for granted. On the contrary, germ theory indicated that it could be prevented, and instances

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therefore had to be explained. In this case, Dr Ritchie blamed the drainage tube. If I had read Dr. Woods paper before the operation, he wrote, I would not have used a drain tube as the cyst was clean, and risk of contamination from the air passages is small. A few country doctors built far wider reputations as specialist surgeons, rather than GPs who operated. One of Dr Littles neighbours in the Wimmera district of northwest Victoria was Dr Tom Ryan, who moved to Nhill, 100 kilometres west of Warracknabeal, in 1898. Dr Ryan was described as erect, stern, uncompromising, with a passion for surgery.190 Over the years, Dr Ryan gradually set up what was effectively a training school for country general-practitionersurgeons. Each patient was carefully examined, including using the X-ray machine, and any surgery was discussed and planned with Dr Ryans assistants several days in advance. He worked the nurses and his assistants very hard and the story is told of one of his assistants fleeing through a back window and catching the train back to Melbourne. We may suspect that it took a strong-willed patient to argue about their treatment with that kind of personality. Dr Ryan developed a considerable reputation in the surrounding areas, including across the border in South Australia, and by the 1920s, patients were travelling to Nhill by train from a wide area, often staying in what was known as Ryans wing of the local hotel. Soon after the formation of the Royal Australasian College of Surgeons in 1927, he was made one of the Fellows, a rare accolade for a doctor outside any of the major cities.

Becoming a surgeon and travelling to learn


Surgery was taught as a part of the general training of a doctor, and every doctor was theoretically entitled to perform surgery, even if he or she had received no additional training or qualifications. However, some doctors spent more of their time operating than others. In Britain, there was a distinct difference between elite surgeons, with honorary appointments at the famous teaching hospitals, full-time surgeons with appointments to less prestigious hospitals, and general practitioners who also performed surgery. However, many full-time surgeons, and virtually all members of the surgical elite, could be distinguished by the letters FRCS after their name. They had passed the examinations admitting them to Fellowship of a Royal College of Surgeons, whether of England (FRCS Eng), Edinburgh (FRCS Ed), or Ireland (FRCS I). Membership of the Royal College of Surgeons of England (MRCS) was one of the most common nineteenth-century qualifications for general practice as a doctor. In contrast, the FRCS was a higher qualification, taken by those who intended to make their living as specialists in surgery. In Australia and New Zealand, members of a small elite group held Fellowships of one or other of the British colleges of surgeons and there was also a larger group without specialist qualifications, most of whom had become full-time surgeons on the basis of a combination of inclination and experience. Australian and New Zealand surgeons kept up to date with events elsewhere in the world at least partly by reading the international surgical journals, and general practitioners with an interest in surgery were likely to buy the latest British or American surgical text books. But as Harry Collins and other sociologists of science have

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pointed out for scientific experiments, they are very hard, if not impossible, to replicate for those who just read written information about the experiment.191 Collins highlights the importance of detailed first hand knowledge of an experiment in order to successfully replicate it elsewhere. This is equally true for surgery, and it is therefore perhaps more surprising that procedures were attempted from the book than that surgeons travelled to learn.192 New surgical procedures are hard to learn by just reading published descriptions, especially when the procedure is in any way conceptually novel. In the early years of the twentieth century, the runaway success of Chicago surgeon Franklin Martins wet clinics, where he provided the opportunity to watch surgery performed, set in train the formation of the American College of Surgeons. By then, Harvey Cushing, William Mayo, George Crile and other elite American surgeons had already organised a surgical travelling club to watch surgeons at work around America, and subsequently also around Britain and Europe. The idea became popular and other surgical travelling clubs were formed in North America and Britain.193 Travelling to learn was associated with a clear appreciation that not everything necessary for the successful performance of an operation could be specified in a written text. As historian of science Mario Biagioli puts it: the knowledge necessary for the successful replication travels with bodies and not only with texts.194 Similarly, David Turnbull argues that a vital component of local knowledge is moved by people in their heads and hands.195 There was also a strong element of scepticism. Surgeons were disinclined to believe published results if they conflicted with their own experience. From at least the 1890s, Australian and New Zealand doctors continued to travel to learn after (and sometimes long after) they had obtained their initial medical qualifications. This did not just apply to surgeons. Like doctors from elsewhere, for instance, Australian and New Zealand physicians flocked to Germany in 1895 to learn about diphtheria anti-toxin. While the pattern of visiting Germany and France was in decline long before World War I, Australian and New Zealand medicine was never isolated from events in Britain. Further, despite the enormous distances involved, there was an increasing trend towards travelling around the world, traversing the United States as well as visiting Britain, in the search for first hand information on the latest developments. Australian and New Zealand surgery developed within an asymmetrical international context, where many, if not most, Australasian surgeons travelled overseas to watch and learn, some of them making repeated study trips during which they might or might not also acquire additional specialist qualifications. But British and American surgeons virtually never travelled to Australia or New Zealand to learn. If they made the journey at all, it was to teach. Australians and New Zealanders founded their own college of surgeons in 1927, and well over one third of the 207 senior full-time surgeons who they enrolled as Founding Fellows had both Australasian and overseas qualifications. Those surgeons who had set out to specifically obtain post-graduate qualifications in surgery had gone to enormous trouble and expense to do so, travelling to Britain and spending time there studying for a fellowship of one of the British colleges of surgeons. But this is only the tip of the iceberg. Many more surgeons had spent time studying surgery overseas without necessarily taking a British fellowship, and many made multiple study trips overseas. Brisbane surgeon Lillian Cooper, for instance, made two extended study trips to Britain and America, without taking a British fellowship.196

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She also had a prolonged opportunity to study overseas surgery, serving in the middle-east during World War I. Sydney surgeon Robert Gordon Craig never took a British fellowship, but he made overseas study trips every five years, including multiple visits to the Mayo Clinic. Where we have biographical details, it is clear that a great many surgeons travelled overseas to improve their surgical knowledge, whether or not they took any further formal qualifications, and as a group, surgeons were extraordinarily well travelled. By the early 1930s, well over half of those admitted to Fellowship of the new Australasian College of Surgeons had practical exposure to the way surgery was performed outside Australia and New Zealand, and in the 1920s and 1930s, more than a third of Australian and New Zealand surgeons held qualifications from both sides of the world. This pattern of travel was particularly characteristic of the more prominent surgeons, the ones for whom there are press cuttings and biographies and who were awarded knighthoods. Comprehensive information is simply not available, but provincial surgeons may well have travelled overseas less frequently. However, only a few of those surgeons who held major teaching hospital appointments had no overseas experience, and Australian and New Zealand surgery, especially at the elite level, was very much exposed to developments in surgery elsewhere. Despite the distances involved, Australasian surgery was never isolated from events in Europe or North America. There was also considerable exchange of information and ideas between the Australian States and New Zealand. Australasian doctors tended to act as a medical block. They shared journals, they shared organizations and they shared conferences, and many of them travelled between the Australian States and New Zealand on an almost annual basis to attend such conferences. At any of the many Australasian medical conferences in Sydney or Melbourne in the early twentieth century, there were likely to be more delegates from New Zealand than from Western Australia, and important Australasian conferences were also held in New Zealand and Queensland. Interstate and trans-Tasman rivalries were important, but there was also a great sense of Australasian collegiality. This was furthered by the social side of medical conferences. Surgeons were not just disembodied intellects; they were men (and sometimes women) of their times. From an early date, their gatherings to exchange information and ideas were also social events. Surgeons and their families were members of the travelling classes, a distinct social elite. Just as an example, the box shows the social events which were organised in conjunction with the fifth session of the Intercolonial Medical Congress of Australasia in Brisbane in 1899. This conference was attended by more than 160 doctors, including three women, and while there were social functions almost every afternoon, all the mornings were devoted to listening to papers presentedby delegates.

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Social Program Intercolonial Medical Congress of Australasia, Brisbane, 1899


Sunday 17th September: Four church services, representing four different Christian denominations (none of them Catholic), attended by doctors and their wives, the governor and his wife, the Premier and his wife and the mayor and mayoress of Brisbane. Monday 18th September: Afternoon Mayoral reception with tea, refreshments and speeches, attended by doctors and their wives, at least three women medical students, the Mayor and Mayoress of Brisbane and other dignitaries. In the evening, there was a ceremony in Centennial Hall attended by both sexes, and featuring a speech by Lord Lamington. Tuesday 19th September: Afternoon art exhibition, followed by an evening garden party in the Botanic gardens, which was rained off. Wednesday 20th September: Between 400 and 500 guests, including Lord and Lady Lamington, attended the Presidents Ball. Thursday 21st September: Afternoon, reception on the lawn at Government House with 1000 guests. Friday 22nd September: Afternoon picnic up the river hosted by the Premier, Hon J. R. Dickson, with 300 400 guests. Saturday 23rd September: Afternoon picnic on the river, with five steamers and 800 guests.

World War I
War gave its own particular impetus to overseas travel and experience. Many Australian and New Zealand surgeons went to South Africa during the Boer War, but World War I had an especially important impact on Australasian surgery. In 1914 newly qualified doctors in particular volunteered for the armed forces. While older doctors volunteered, too, there was something of an exodus of those in the younger age groups who had qualified in the two or three years before the war. They went to Europe to work, rather than to study, but never the less, steep learning curves were an almost universal experience for this generation of doctors. They learned new skills from the thousands of wounded men returning from the front, and they participated in the development of the emerging specialties of plastic surgery and orthopaedics.197 But for many, the immediate post-war era was as important for their careers as the war itself. Under an Empire-wide scheme, dozens of young Australian and New

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Zealand surgeons took up the opportunity to remain in Britain and study for the Fellowship of the Royal College of Surgeons of England. After the war, many, if not most, Australian and New Zealand specialists continued the pattern of spending some time learning their craft overseas. Neurosurgeon Sir Douglas Miller, cardio-thoracic surgeon Rowan Nicks and orthopaedic surgeon McKellar Hall are just three examples. A number of the early Australian urologists also seem to have been both prepared to travel and very willing to learn from urologists in Britain and America. Keith Kirkland from Sydney and Henry Mortensen from Melbourne, for instance, were famous for the frequency with which they travelled to overseas surgical meetings. Those who travelled could see for themselves what was possible with the new techniques. Poor results when operating from the book could be understood as the fault of the surgeon, not the new procedure, and practice could be followed by better results.

Urban specialists
In the 1890s, there were relatively few specialists and very few specialties. Medicine, surgery, obstetrics and gynaecology, ophthalmology and ear nose and throat (ENT) specialists were the main ones recognised by their peers. However, many people who specialised in one of these areas continued to practice in another, and/or to act as general practitioners to their private patients, because they were not seeing enough patients in their chosen specialty to make a living from that alone. In the 1930s, for instance, Charles Augustus Thelander, who published in the area of gynaecology and was recognised as a gynaecological surgeon by the infant Royal Australasian College of Surgeons, continued to perform appendicectomies and other general surgical procedures. By the 1930s, the range of recognised specialists had increased enormously to include radiologists and pathologists, plus specialists within the broad field of surgery such as urologists, plastic surgeons and orthopaedic surgeons. The medical codes of practice did not allow them to directly advertise for patients, and so they all relied on their reputations with their GP colleagues to refer patients to them. While general practitioner and rural surgeons needed to somehow make themselves known to potential patients, specialist surgeons needed to make themselves known to their colleagues, in order to attract referrals. Australian doctors with honorary appointments to teaching hospitals found it far easier to build a reputation for special expertise than their country colleagues. A busy private practice was a clear marker of success, but obtaining a public hospital appointment was the most visible bench mark of a career that was well on the way. An honorary appointment at a major teaching hospital represented peer acknowledgement of competence. Consequently, members of the surgical elite were identified by their public hospital appointments, listing them at the beginning of their journal articles. This marked their status as specialist surgeons, as opposed to general practitioners who sometimes performed operations. The other marker of their status was the address of their consulting rooms. In their private practice they were identified not by the private hospital where they operated but by the street on which they worked. Some particularly independent minded individualists did not conform, but most

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specialist surgeons (and physicians) clustered together in clearly defined locations. In Sydney, this was on Macquarie Street and in Brisbane it was on Wickham Terrace. In Melbourne it was on Collins Street and the phrase Collins Street surgeon clearly marked a doctor out as being what Christopher Lawrence has called a medical aristocrat, a specialist rather than a general practitioner.198 It was their consulting rooms, rather than any particular hospital, that formed the public, and possibly also mental, focus of their private practice. While some surgeons were flamboyant exponents of self-promotion, the practice style that came to dominate the public image of surgeons by the 1930s was that of members of the social elite who had chosen a life as hard-working experts in the public interest. Images, of course, do not always have a substantive basis, but the surgeon who was perhaps most promoted by his admirers as fitting this picture was George Syme. In his biographical sketch, Ivo Vellar noted that his nickname was Silent Syme. A man of great intelligence, a clear thinker noted for his probity and strict adherence to ethical standards199 When delivering the second Syme Oration in his honour in 1933, F. Gordon Bell noted that Symes professional utterances were weighty and carefully considered and that he was essentially a safe surgeon, with a profound influence, in his silent and unobtrusive fashion, on surgical thinking in Victoria.200 Symes uncles were the founders of the Age newspaper and his family sent him to Wesley College and the University of Melbourne, and then on to England in 1885, where he obtained surgical experience and the FRCS. He returned to an appointment as outpatient surgeon to the Melbourne Hospital in 1887, but did not make it to the top rung of the ladder as surgeon to inpatients until 1903. Meanwhile, he was happy to accept the position as foundation inpatient surgeon to St Vincents Hospital, opened by the Sisters of Charity in 1893. The surviving surgical case books from St Vincents confirm Gordon Bells opinion that he was a relatively conservative and safe surgeon, not inclined to take risks on his patients behalf, but he could also be innovative at times. The overall image from the comments of his colleagues and his own publications is of a serious and possibly boring personality who would never knowingly do the wrong thing. By the time that surgeons in Australia and New Zealand decided to found an antipodean college of surgeons in 1927, Syme was nearing the end of his career, but he was also widely respected and the obvious first president. Who better to convince general practitioners that the college of surgeons was not being formed to boost surgical incomes at the expense of their own? Even when he was a young man, it is hard to imagine that patients ever doubted that Mr Syme had their best interests at heart, and by the time that he was knighted in 1924, Sir George was the quintessential example of a trustworthy surgeon. The other venerable hero associated with the founding of an Australasian college of surgeons (and for whom there was also a regular memorial lecture) was Robert Hamilton Russell, an Englishman of the generation who trained under Lister. He migrated to Melbourne early in his surgical career and became known for his innovative repair of both hernias and fractures. Unlike Syme, he was also known for his eloquence, but it was a gentlemanly and reserved eloquence, and one of his many affectionate obituaries emphasised his gentle dignity.201

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But not all surgeons had such a benign image. Hamilton Russell and Symes near contemporary, Sir Alexander MacCormick, for instance, was probably a more brilliant technician than either of them, and even more famous in his day, but he was remembered for making a fortune from his Sydney private practice, rather than for quiet probity. In his essay on the history of surgery at the Royal Prince Alfred Hospital, H. H. Schlink associated MacCormick with daring surgical triumphs.202 Douglas Miller was one of his admirers and told the story that when Nellie Melba was dying, MacCormick said She wanted to rent my house once. Id as soon lend my shirt as my house, and that MacCormick was exacting and unsympathetic with Jews and graziers.203 It is difficult to imagine anyone telling such stories about Syme or Hamilton Russell, although there is no doubt that doctors attitudes to patients varied enormously and there were a number of widely held prejudices. There are few examples of doctors who had a good word to say about the drunk, the dirty or the overweight, for instance. Quiet digs in case reports such as: more vigorous cleansing of his skin, of which he was much in need, were not at all uncommon.204 A doctors success was linked to their reputation, whether with patients or with colleagues, and not all doctors had a good reputation. Alexander Francis, who later specialised in ENT surgery, began work as a general practitioner in Barcaldine in 1892 with what he described as a lucky case. A well-known local resident was suffering from typhoid. The patients life hung by a thread for some weeks, he wrote, but she recovered and after that everything was easy for me.205 But Dr Francis noted that a colleague in a neighbouring town, who he was sure was a perfectly competent doctor, had a run of bad outcomes in his first few weeks and had to leave town. The man was never able to gain the confidence of his Queensland patients, but went on to a successful practice in New South Wales. For country doctors such as this, it was a local reputation with patients that mattered most. For city specialists, the position was rather different. Douglas Miller, one of Australias first neurosurgeons, decided to specialise in surgery quite early in his training and spent some time as an informal apprentice to Sir Alexander MacCormick in Sydney. In his autobiography, Dr Miller argued that this experience was enormously important for his future career, not only because of the valuable lessons he learned from MacCormick, but also because of the network of relationships that he built up among Sydneys leading physicians. In the 1930s, when Dr Miller finally went into practice as a specialist in his own right, after a prolonged period gaining surgical experience in both Sydney and London, some of the most eminent physicians in Sydney already knew who he was and had formed an opinion of his character and competence. They were an important source of patient referrals as he built up his private practice. Douglas Miller also built a reputation for himself in Sydney as a lecturer in anatomy and surgery as well as through his honorary appointment at St Vincents Hospital. These were highly competitive appointments and Miller only succeeded in winning them after acquiring considerable experience, including a prolonged period of study in England. The road to successful private practice as a specialist was a long one, requiring an almost obsessive interest and total involvement in the work. Another wonderfully exciting case [wrote Douglas Miller] was that of a young girl who for some time had been very unsteady on her feet and had frequent falling attacks before developing severe headaches and failure of vision On opening

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her head I immediately encountered a large circumscribed cystic tumour The referring physician was watching and I remember his excitement when he hurried out of the theatre to report all the details of what was the first modern brain operation he had seen206 Miller did not mention discussing the risks of this novel sort of surgery with the patient and her family, or having any trouble in persuading them to consent. He simply took it for granted that he knew what was best for her. Specialists might be well into their thirties before they began making a significant amount of money, but meanwhile, they had acquired experience, they had acquired expertise, they had acquired confidence and they had acquired status with their colleagues.

Surgical lifestyles A: Work


In Melbourne in 1932 at the fifth annual meeting of the Royal Australasian College of Surgeons (RACS), leading surgeons demonstrated operations at the Melbourne, St Vincents, the Alfred, the Womens, the Childrens and the Eye and Ear hospitals. All of these were public hospitals. They were supported by a combination of charitable donations, government subsidy, contributions from those patients who could afford to pay something towards the cost of their treatment and various other (often ad hoc) fund raising activities. All these hospitals had some full time medical staff, but the senior medical staff essentially worked part time, for free, under the honorary system. At the 1932 meeting, the College did not organise a single operative demonstration at any of the 207 private hospitals in Melbourne, where patients paid the hospital the full cost for their care and also (separately) paid their doctor. There are many possible explanations for this, including the generally smaller size and poorer facilities of private hospitals in this era. But the straightforward reason is that private hospitals were not used for teaching. Medical students did not follow surgeons or physicians through the wards and cluster round beds to hear their verdicts on diagnosis and prognosis. Private hospitals were private. In Australasia, as in Britain, (but not in the United States) the undergraduate teaching hospitals were all public hospitals. The postgraduate education of surgeons also relied increasingly on public hospitals. Trainee surgeons spent most of their time observing their seniors and gained little practical hands-on operative experience, but what experience they did get was generally on public hospital patients, especially in emergencies and after hours. For instance, in 1927, Douglas Miller went to England to study for the FRCS. Despite the fact that he had witnessed and assisted at a vast number of operations he got his first personal operating experience on poor law patients at the Hackney Hospital in the East End of London.207 It therefore seemed natural to the surgeons organising the program for the 1932 meeting of the RACS (Alanlater Sir AlanNewton and Hughlater Sir HughDevine), that all operative demonstrations would be at public hospitals. They were accustomed to performing public surgery, that is to say, performing in front of an audience of medical students and other doctors, on (poor) public patients in public hospitals.

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Surgeons were identified by their public hospital appointments. A ten-page article on Sir Hugh Devine, for instance, has two separate sections devoted to his role at St Vincents Hospital, Melbourne, but does not once mention a single private hospital (in Australia) where he worked.208 This is not a failing of the article. It simply reflects the fact that surgeons were not identified by their private hospitals. Devine lived in the prestigious suburb of Toorak, he sent his three children to elite private schools and he and his family made multiple trips to America, Britain and Europe. On one trip to Europe he had an audience with the Pope and on a subsequent trip to England, his daughters were presented at Court in London. Yet Devine did not make any of the money to pay for all this at St Vincents Hospital. His work there was part time and unpaid. Neither did he come from a wealthy background. He made a substantial income in the time left over from his very public work at St Vincents through his private practice. Public hospitals depended on private hospitals. The one could not exist without the other. This was not because of direct cross subsidy (although this was an important component in the financing of Catholic health care). It was because surgeons (and physicians) worked for free in the public hospitals. They therefore had to make a living somewhere else. The result was a symbiotic relationship between two interlocked economies, one driven by market forces, and the other a moral economy, driven by the logic of a gift relationship. In the first half of the twentieth century, the annual reports of Australias public hospitals were a part of the cycle of exchange in a gift economy. Essentially, they were documents designed to publicly acknowledge gifts and to tell the donors what had been done with their time or money or gifts in kind. The Melbourne Hospital reports, for instance, began with a statistical summary of the number of doctors, nurses, patients, beds and operations performed (page 1) and then provided a tear out form for subscribers to fill in, either making a donation or leaving a legacy (page 2) before the title page: Melbourne Hospital Report of the Committee of Management with Statement of Accounts Lists of Subscribers and Donors and Statistical Returns for the Year Ended 30th June.209 The Annual Reports of the Mater Misericordiae Public Hospitals in Brisbane generally began with a straight-forward statement of purpose. For instance: The Sisters of Mercy have much pleasure in presenting to benefactors and subscribers the First Annual Report of the Mater Childrens Public Hospital.210 The Mater Annual Reports listed gifts in kind as well as in cash, so that we learn that in 1932 (mainly for Christmas) fifty named individuals and ten organizations made gifts of food or clothing. These included pumpkins, donated by Mrs. A. Bulgar, turkeys from Mr. Hickey, pillow slips from Mr. Laird and pyjamas, dressing gowns and face washers from the All Hallows Needlework Guild.211 Catholic hospitals relied particularly upon gifts from members of the wider Catholic community. While few Catholic doctors worked at the Melbourne Hospital, many doctors who were not Catholics worked in Catholic hospitals and the records of Australias Catholic hospitals are full of the names of Jewish doctors, for instance. But overall, it appears that both the Melbourne Hospital and the Mater in Brisbane had broadly similar relationships with their medical staff. Prominently placed in their reports was a general acknowledgment of the work of the honorary medical staff and a listing of their names, qualifications and precise honorary positions. Honorary medical staff were literally honoured by the hospitals for the

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gift of their time and expertise. The Melbourne Hospital Reports, for instance, feature the dates of graduation and appointment through the successive ranks of the hospital hierarchy for each Honorary Medical and Surgical Officer. The exact sequence of appointments varied a little but the basic pattern began with an appointment as resident medical officer (RMO), possibly followed by a period as Registrar, and/or Medical Superintendent.212 None of these were specialist surgical or medical positions, and they were all paid. Those who wished to specialise as surgeons at the Melbourne might spend a period as Surgical Clinical Assistant. Then came the great divide between the paid and honorary positions. Honorary staff typically spent a period as Surgeon (or Physician) to Out-patients, before the ultimate achievement of a position as Surgeon (or Physician) to In-patients. After retirement, some were honoured with an appointment as Honorary Consulting Surgeon (or Physician). Public hospitals were places where gifts were given, received and acknowledged. But they were also places for teaching and learning and had been since long before there were any hospitals in Australia or New Zealand. Education was a part of the moral economy of gift exchange within the public or charitable hospital. The wards and operating theatres were also classrooms, not only for doctors, but also for nurses. Much of the kudos of honorary appointments was precisely because they were at teaching hospitals. Unlike the system in the United States, where teaching and research were not confined to public hospitals, in Australia and New Zealand, as in Britain, teaching and research took place at public hospitals, where doctors made the gift of their time and expertise. The position of honorary surgeon to in-patients at a major teaching hospital had many advantages, not the least of which was that there was virtually no one in a position to tell the incumbent what to do. Many were highly conscientious about their visiting times and their teaching responsibilities, but the stories about those who were not, are sufficiently common to make the point that honoraries did not have to come and go at set times. The jokes in the Melbourne medical students magazine about surgeons rushing out of the operating theatre to go and play golf are just one example.213 Honorary surgeons could play golf or tennis on week days if they chose, or they could work 14 hours a day, seven days a week. They were the aristocrats of the hospital world, their own masters (or mistresses), free to come and go as they pleased. For while the public hospitals gave them thanks second only to God, the private hospitals were even more concerned to keep their good opinionand the business they brought with them. While doctors competed for positions as honorary consultants at the major public hospitals, private hospitals wooed the doctors to bring them their patients. Public patients chose their hospital. That is where they went, and they were treated by which ever student or junior doctor happened to be on duty at the time. Private patients and/or their GPs chose their surgeon. The surgeon then generally made the decision as to where the patient would be treated. Private hospitals therefore depended on doctors to bring them business. It did not often walk in off the street in the same way as patients flooded into the public hospitals. Within this system of interlinked public hospitals and private practice, surgeons came to enjoy enormous status and prestige both with the private hospitals, which depended on them to bring in patients, and with the public hospitals, which depended on them to work

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(and teach) on an honorary basis. The whole structure of this moral economy of medicine supported the status of elite surgeons (and physicians) as heroes, especially those who worked hard, built up large public hospital departments and ran busy private practices.

Surgical lifestyles B: Social life


Surgeons did not just travel to learn. They travelled for pleasure. Successful surgeons belonged to the upper middle class and in the inter-war years, this was associated with a very specific life style. Women of this class seldom worked for money, although there were a few doctors and other professionals. More often they worked for free. It was expected that they would spend several days a week working for charity. Even those women who had professional careers were expected to work for charity in their spare time. In 1932, for instance, under the heading The Womans World, the Melbourne Herald ran the following item: Among interstate delegates who have come to Melbourne to attend the Royal Australian [sic] College of Surgeons fifth annual conference, which will open this evening, is a woman surgeon, Dr. Connie DArcy of Sydney. She has been here for a week staying at the Quamby Club. Although her profession comes first, Dr. DArcy manages to find time to participate in a number of welfare movements for the betterment of women and children214 Upper-middle-class women sat on committees and organised small armies of women who ran fetes and stalls and flag days for the Red Cross, or the Society for the Prevention of Cruelty to Children, or the hospitals. It was not only surgeons who were involved in the moral economy of gift exchange. So were many of their wives. They were members of what Kerreen Reiger has called the upper-middle-class charity network.215 Whether they were raising money for worthy causes or simply enjoying themselves, the activities of members of this group were regularly reported in the social pages of the newspapers. Such news items were intensely formulaic. The reporter noted what the hostess was wearing and the flower arrangements, mentioned the venue and the occasion, and then listed the guests, beginning with the most famous, and/or those perceived to have the highest social status. The following extract from the Canberra Times is a typical example: Gowned in a plum coloured georgette frock, trimmed with fine lace, and a black hat relieved with the same colour, Mrs. Earle Page was hostess at an afternoon tea given in the drawing room of the Hotel Canberra in honour of the wives and visiting doctors Lord Stonehaven, the Governor-General was present, and before tea Mrs. Earle Page presented the ladies to his Excellency. Among those present were Mrs. Gordon Craig (Sydney), Mrs. Sandes Dr. Lilian Cooper.216 This report concerns a function held in association with the first Annual Meeting of the College of Surgeons of Australasia in Canberra in 1928. For members of the upper middle

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class, there was a distinct rhythm to the cycle of the year. While the opening of the duck shooting season (in 1932, it was on the weekend before the College of Surgeons meeting in Melbourne) did not have the same social cache as the opening of the grouse shooting season in Scotland, the autumn horse racing carnival was the focus of a significant round of social events, and the spring racing carnival, especially the Melbourne Cup on the first Tuesday in November, was as much an elite social event as any horse race in England. Some women made a trip to London every few years, had their frocks and gowns made in Paris and returned to Australia in time for Cup Week. Select Melbourne and Sydney dressmakers also made the pilgrimage to Paris, and returned to make copies of the latest fashions for those who could not afford to travel to France to buy the originals. Young women still came out and their mothers arranged balls for the purpose. A select few enjoyed the season in London and were presented at Court. This class was no more immune from the effects of the depression than any other. Between 1929 and 1932, the big private balls more or less came to a halt. However, charity balls continued. In some instances, these were effectively more or less private parties, where most of the guests knew each other. The difference was that they had all paid for their tickets, with any money left over after the cost of the function going to a worthy cause such as the Childrens Hospital. While there were parties associated with the First Annual Meeting of the College in Canberra in 1928, the next few meetings were more austere. At the third meeting, in Melbourne in 1930, for instance, the motto of the conference was strictly business and there were no entertainments. The garden party at the University of Melbourne in February 1932 was something of a half way house, before the full flowering of the social program in the later 1930s. Sir Holburt Waring, President of the Royal College of Surgeons of England, opened the headquarters building of the RACS in Melbourne on 4 March 1935. The College invited surgeons from all over the English speaking world, and many accepted the invitation. The opening was timed to coincide with the autumn racing carnival, and the meeting was incorporated into the celebrations surrounding the centenary of the City of Melbourne.217 Melbourne has been very gay during last week and many overseas and interstate visitors have been in town to attend the races, watch the progress of the polo tournaments, and take part in the varied festivities associated with the coming of the autumn season. A number of distinguished visitors came for the congress of the Royal Australasian College of Surgeons, and on Sunday afternoon Mrs. Hugh B. Devine (whose husband is vice-president of the College) gave a delightfully planned party at their home in Woorigoleen road, Toorak, at which the special guests of honour were the president of the Royal College of Surgeons of England (Sir Holburt Waring), the president of the Royal Australasian College of Surgeons (Sir Henry Newland) and Lady Newland, the president of the American College of Surgeons (Dr. Donald C. Balfour) and Mrs. Balfour, Sir DArcy Power (London) and Miss Angela Power218 That week, Mrs. Alan Newton, Lady Newland, Mrs. B. T. Zwar and Mrs. Victor Hurley all gave parties for the surgeons and their wives, including visitors from England, Scotland, Canada,

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South Africa and the United States. All were reported in the papers, and the Melbourne public was also well informed about what Miss Angela Power and Mrs. Balfour (described as distinguished overseas visitors) wore to the races. The comings and goings of members of this class were regularly noted in the social pages, as they got on and off ships. Successful surgeons and their wives and families were integrated into a moral economy of working for charity, but they were also members of the travelling classes. Repeated study trips abroad fitted seamlessly into this way of life.

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Chapter 6: In Theatre
This chapter uses personal diaries to follow surgeons into the operating theatre.219 It considers the culture of surgery and the normative value placed on truth-telling and accepting responsibility for mistakes and examines some of the pressures to regulate the performance of major surgery. This material allows an examination of the distinctive code of morality amongst at least some early-twentieth-century operators and asks how they judged their own and their colleagues behaviour.

Inside the black box


By 1900, the blow by blow details of surgery were ceasing to be publicly visible. Surgery in private homes was becoming uncommon, and in hospitals, ritual adherence to germ theory had the effect of distancing spectators in operating theatres from the operative field. Not many people were in a position to see exactly what was going on, and by the turn of the century those spectators were effectively limited to surgical insiders: surgeons, anaesthetists, theatre nurses, house surgeons, medical students and visiting surgeons from elsewhere. For the public, the wonders of modern surgery were becoming effectively black boxed. They knew what went in; they knew what came out; but what happened inside operating theatres was largely a mystery. Nobody was in a position to tell surgeons or, as they were generally called in the early years of the century, operators, exactly what to do, although they were subject to some constraints, including from their peers, the courts and public opinion. But the lack of outside regulation of surgery meant that any doctor was permitted to operate, whether or not they had any special training or experience. Which operations they performed, and how they performed them, were matters for their own moral and clinical judgment. The only effective day-to-day regulation of what happened on operating tables, inside the black box, was self-regulation, by those who were doing the operating. Surgeons, however, worked inside the black box. They knew better than anyone what went on there. In particular, they knew that results varied and mistakes were made. Even experienced operators made mistakes, and they were especially aware of the kind of errors that could be made by doctors who did not operate as often as they did. A number of sources have survived from the early years of the twentieth century, which allow us to glimpse how surgeons judged each others behaviour. The most detailed of these are the diaries of Adelaides first Professor of Anatomy, Archibald Watson.220 Watson, who had medical degrees from Gttingen and Paris and was a Fellow of the Royal College of Surgeons of England, has long been a controversial figure in Australian medical history, but he left an extraordinary legacy for the history of surgery.221 For many years, he recorded the surgery that he watched, and the surgery he performed himself, in a series of small notebooks. Watsons diaries allow a rare glimpse of what was happening inside the black box of early twentiethcentury surgery, and they are particularly valuable because they record surgery in private

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practice as well as in public hospitals, and they do not just provide information on the work of one surgeon. Watson recorded watching operations performed by many of Australias better known surgeons. In 1900 he spent time in South Africa, observing and working with British and American surgeons during the Boer War, while the outbreak of WW I saw him heading for Europe as a consulting surgeon to the armed forces, and commenting on the work of the surgeons he saw there. Over the years, he made notes on literally thousands of operations performed by many of Australias leading surgeons, especially in the period 18971920. Watsons diaries offer a glimpse of one mans view of surgical standards, both in terms of technical competence, and in terms of accepted norms of behaviour within the culture of surgery.

Normative errors
To the lay reader, Watsons notebooks are quite startling on at least two counts. The first of these is the catalogue of errors that they record, and the second is their air of painful honesty, not only about the surgery of others, but also about the surgery performed by Watson himself. One of the particularly disastrous cases that he described involved a woman who was being operated upon at the North Adelaide Private Hospital in 1919, for complications following the removal of ovarian cysts two months earlier. She returned to the original surgeon with pus in her wound and faeces in her vagina and Watson was present to assist: Pat is extremely wasted and going down hill. In an evil moment I advised reopening abdomen & seeing what was the matter came on a thin fluctuant cyst as it cd not be bladder (sic)222 I made a small puncture in the wall. Out came straw coloured urine. Before I cd sew it up I allowed the urine to escape and it was then that my fellow operator plunged in his fingers & tore the bladder from top to bottom oh fool! Why did I not insist on first reopening the recent cul de sac before attacking the abdominal tumour (or distended bladder) 223 Watsons pain at his error is almost palpable, and his records of cases such as this have the air of the confessional about them. He does not make any excuses for mistaking the bladder for a cyst, and he may well have adhered to what was later a very strong surgical code of owning up to, and accepting responsibility for, mistakes.224 We do not know whether Watson accepted responsibility for his mistakes in public, but he certainly seems to have been honest with himself and accepted responsibility for his mistakes when he wrote in his diary about what he had done. That some, at least, of his contemporaries adhered to a similar code is clear from the following quote from an article in the Lancet by Melbourne surgeon Hamilton Russell, when reporting a death in a series of sixty cases of operation on children for inguinal hernia: The cause of death was suppuration of the ligature, placed upon the neck of the sac. For this unfortunate occurrence I take the entire blame upon myself; the calamity was a perfectly avoidable one, and was the result of my being persuaded to employ a ligature material which I had not sufficiently tested beforehand225

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It should be noted that in this era surgeons generally took responsibility for sterilising their own suture material.226 In the very public forum of the pages of the Lancet, Hamilton Russell was displaying one of the key characteristics of a good and moral surgeon, by accepting responsibility for a failure in aseptic technique. By speaking out and taking the blame upon himself for the lapse in sterility of the suture material, Russell saved himself from what could have been a normative error in failing to own up to his contribution to a preventible death. The second normative value that Watson seems to have displayed in his own behaviour is that he cared deeply about the patients. In 1947, Adelaide surgeon Sir Henry Simpson Newland recalled the first post-mortem examination he attended as a medical student, in 1893. It was: on a beautiful young woman who lay blanched and white as a marble statue, a victim of the unstemmed flow of blood into the abdominal cavity from a ruptured pregnant Fallopian tube. The circumstances made a profound impression on me, an impression which was deepened by the curses and comments of Professor Watson on how the tragedy might have been prevented.227 For Watson, incompetent bungling seems to have been a third category of normative error. As an anatomist, he took a particularly dim view of surgeons who made mistakes because they were ignorant of the relevant anatomy. But what seems to have made him most angry was not honest mistakes, owned up to and where possible carefully corrected, but ignorant bungling by people who he believed should never have attempted to operate in the first place because they did not have the requisite knowledge and skills. Except during the Boer War and during WW I, he made notes on very few operators who fell into this category, precisely because such people were not his colleagues, let alone his friends. He did not want to watch what they were doing. A rare example was in January 1910, when he watched an operation on a football players knee at the Adelaide Hospital: knee gets locked occasionally and lays him up with synovitis With this history wd it be believed that the operator anchored dorsal expansion of quadriceps with a needle after taking the advice of his HS [house surgeon] cut down with negative results then being told there was a partial displacement of internal semi-lunar anchored same I was called away to case on next page & did not see the patella sutured & c God forgive me for looking on as long as I did.228

Technical errors and surgical uncertainty


It has been customary to discuss surgery in the early twentieth century by looking at it through the glass half full of surgical cures, at those patients whose surgeons achieved their objectives, whose wounds healed by first intention and who went home cured or relieved. In the glass half full story, the story from hospital statistics of ever more patients and ever more operations, as well as the story of innovative surgeons devising ways to fix more and more difficult problems, virtually the only complication that is ever noted is death. But that is a very coarse sieve for sifting out the surgery that permanently removed the patients

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symptoms from the surgery that did not; the surgery that was competently performed by an expert from the surgery that was bungled by a novice; the surgery that was performed because the patient needed the operation from the surgery that was performed because the surgeon needed the money. An alternative way to look at early twentieth-century surgery is to consider the issues that might be characterised as belonging to the empty half of the glass. Recent statistics from the United States suggest that something like one in twenty five patients admitted to hospital experience an adverse event, that is to say, something goes wrong, and of these events, one in four has been assessed as being due to medical negligence.229 We do not have comparable figures for 1910 or 1930, but a closer look at some of the statistics indicates, as might be expected, that adverse events were not unknown to early twentieth-century patients and doctors. Post-operative bleeding is a recognised twenty-first century complication of tonsillectomy, for instance, and a search through the hospital statistics for 1930 indicates that it was also a complication then.230 At least some tonsillectomy patients had to be admitted to hospital from the out-patients departments because of post-operative bleeding.231 We may strongly suspect that the tidy catalogue of operations appearing in the early twentieth-century hospital statistics conceals a rather more messy reality of at least some surgery that did not go according to plan. Archibald Watsons diaries provide confirmation that this was so, particularly for the newer operations, where there was not yet any consensus among surgeons as to whether, when and how they should be performed. By 1900, the descriptions of hysterectomies and appendicectomies in Watsons notebooks are not descriptions by an inexperienced doctor finding his way around the abdomen. They are descriptions by a man who had spent something in excess of 300 days a year for the past twenty years in operating theatres and autopsy rooms, teaching and studying surgical anatomy. Given Watsons role as a teacher, we might expect the notebooks to be full of information on what went wrong when there was a bad outcome or the patient died. But in fact the notebooks are full of something rather different and less orderly. They are full of messy surprises and uncertainty. For instance in May 1899 (when Watson was in Melbourne), he described a case operated upon by Dr M. U. OSullivan. Missaet 22 who diagnosed pregnancy in herself wrote Watson. The woman had cysts on both ovaries and, it turned out, abnormal anatomy. The ovarian ligt. Beat me, wrote Watson. He filled four pages of his notebook with the case, and described and drew several unusual features, including: Two cotylidones of purple succulent appearance I presume these had been adherent to the cyst somewhere[,] like the suckers on a cuttlefish.232 Time and time again, Watson noted details such as this that indicate that despite his considerable experience, he was seeing something he had not seen before in quite that form. Under Watsons watchful eye, surgeons were opening up their patients to reveal surprising and gruesome things, and sometimes they treated them in what Watson regarded as an equally surprising manner. He made no rude comments about OSullivans treatment of the woman with something like cuttlefish suckers in her abdomen, but a few days later he was clearly surprised by another surgeons treatment of the same category of problem: cystic ovaries.

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On opening abdomen [he wrote] 1 gallons gushed forth of clear straw coloured fluid the parovarian [cyst] was delivered in the most extraordinary fashion as the operator rooted & burst cyst through posterior blade of broad ligament and extracted it through the rent which was not sewn upand may offer a pocket for hernia of sigmoid flexure233

Surgery and uncertainty: Post-operative infection


One category of surgical problem that was widely recognised by the public was death from post-operative infection. By the turn of the century, belief in germ theory and the associated adoption of some version of aseptic operating technique was regarded as underpinning the whole edifice that people at the time called scientific surgery. Post-operative infection was no longer a matter of fate; somebody was now to blame for a lapse in the battle against germs. Never-the-less, post-operative infection continued to occuroften. As was noted earlier, germ theory gave surgeons an intellectual tool that allowed them to believe that post-operative infection could be avoided in theory, but they often failed to achieve this in practice. It is important to remember that the rituals for warding off infection were in their infancy in 1900. Obstetricians often wore gloves, but few surgeons did; virtually none wore masks; special clothing was becoming common in operating theatres, but over, rather than instead of, street clothes and shoes; head coverings were common for nurses but not for doctors; beards were common but beard coverings were an entertaining novelty; foot-operated taps were only just being introduced in some operating theatres, and the ritual dances of surgeons being helped into gloves and gowns by nurses were some way in the future.234 In the early decades of the twentieth century, aseptic procedures continued to change rapidly, but within a general framework of confidence until the outbreak of WW I. However, in the trenches of France and Belgium, optimism about any easy victory in the battle against infection was severely shaken. As Sir Victor Hurley (who worked in Europe as a young surgeon during WW I) put it in 1951, surgeons: Were then rudely disillusioned in their belief that the problems of wound infections had been completely solved Especially on the western front the wounded were often untreated for long periods in heavily contaminated surroundings. Appalling infections resulted and the surgical procedures which had proved satisfactory in civil surgery were completely ineffective in the treatment of these war wounds.235 Error in aseptic technique was essentially contested throughout the early twentieth century, and one surgeons acceptable behaviour might be anothers cardinal sin. Preventing postoperative infection was not a simple matter of doing the right thing. What was right for one surgeon might be considered wrong by another, and accepted practice was changing continuously during the early twentieth century. There was a daily struggle to determine what prevented infection and what did not, and the patients sometimes got better even when surgeons failed to follow the accepted codes of behaviour. In September 1897, Watson was watching a womans ovary being removed and wrote:

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H sneezed twice at an interval of 5 minutes lifted up his apron to cover & wipe mouthdid not disinfect hands after[,] the finger of one of which was twice in pelvis to feel broad ligament see if this pat gets sepsis Oct 13 Pat discharged expressing herself as very well.236 Surgeons might have a clear theory of what caused wound infection and there is no doubt that H had broken the accepted rules for aseptic surgery in 1897, but the patients wound did not become infected and she recovered well from her operation.

Surgery and uncertainty: Multiple operations for the same condition


By no means all operations achieved their objective. Sometimes a surgeon made multiple attempts before the objective of a surgical intervention was achieved. It also sometimes happened that the surgical objective was never achieved, either because the patient refused to submit to further interventions, or because the patient died. Perhaps the people who most often returned to doctors for multiple operations for the same condition were those suffering from hernia: Jan 20th 1910 male act 28 was operated upon in England for a left side ingl hernia perhaps a femoral as pouparts [ligament] appears to have been divided & there is an immense perpendicular scar & bulge. Operator commenced by allowing H. S. [house surgeon] to perform on hernia on the right side. Skin incision good but the rest was chaos a big vessel bled & was tied then operator cut the scar out in a strip (wide) on alternate left side 237 Did the hernia recur because the original surgeon had performed the repair badly, or because no one had yet devised a long term way of repairing herniae? This was essentially a matter for debate, not certainty.

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Surgery and uncertainty: Mysterious outcomes


What was also often a matter for debate, not certainty, was the outcome of operations. Sometimes things went wrong, but the patient recovered anyway; sometimes everything went according to plan but the patient died. In September 1902, for instance, Watson recorded a discussion with an anaesthetist, Dr Mandesley, on the outcomes from surgery to remove cancerous sigmoids: Mandesley said that Rowan diagnosed left ovarian trouble in one pat. where he (Mandesley) thought it was sigmoid and wanted to send case to Bird. Rowan struck impenetrable adhesions but finished by removing a fist sized mass & sewing bowel up very roughly. Pat. recovered without a symptom, whereas Sir

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Thos Fitz planned removal of sigmoid in one case & carried it out very neatly yet pat. succumbed within 2448 hrs.238 In other words, an unplanned and roughly performed operation by a little known surgeon was followed by a good result, while a carefully planned and executed operation by one of the most famous surgeons in the country was rapidly followed by death.

Surgical errors and the diaries of Malcolm Earlam and John Laidley
Another source of information has survived, which gives us the judgments of two Sydney urologists on how surgery was performed in Britain and the United States in the 1930s and 1940s. John Laidley and Malcolm Earlam each made study trips to Britain and North America, and kept diaries of their experiences. Both men were keen observers of the clinical judgment of British and American urologists, and the grounds on which they made the decision whether to operate and which operation to perform. Their notes allow glimpses of Earlam and Laidleys own values and how they assessed the men (they visited no female urologists in Britain or America) they observed. It emerges that they placed a higher value on character and clinical judgment than on technical skill, and in addition they valued enthusiasm and admired those urologists who were continually looking for ways to improve their results.239 Of one American surgeon Earlam wrote: on 2 days acquaintance [he] impresses me as a tradesman who has settled into a routine method of doing most things and is thus saved from having to do any great amount of mental exercise about his patients. So far he impresses me, generally, less than anyone I have met here.240 Earlam and Laidley seem to have shared Watsons attitude to technical skill. Lapses in skill or technique did not necessarily mean that they did not respect, or even admire, the surgeon concerned. For instance, Laidley watched Reed Nesbit remove a stone from a ureter and noted: He dug for some time into a deep dark hole and produced the ureter eventually not impressive He is apparently the instrumentalist rather than the surgeon241 But clearly Laidley was enormously impressed with Nesbits skills in performing the difficult new operation of transurethral resection of the prostate: If [Fred] Foley is considered a good resection merchant, then we are too. Actually none of us have even touched the fringe of good resection as demonstrated by Reed Nesbit.242 Fred Foley is another example of a urologist for whom both Earlam and Laidley clearly had a warm regard that had nothing to do with his level of technical competence. It seems rather to have been Foleys boundless enthusiasm for continually coming up with new procedures and new instruments to try and do things better that was so impressive. Earlam was also impressed with Vincent OConor in Chicago, praising his careful consideration of cases and conservative approach, but his comments on OConors surgery emphasise the unpredictability of results: He has had the same experience as we have, vis. Some of the resections he has been most pleased with have been followed by the worlds worst results while others that looked like the dogs dinner have turned out 100%.243
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Good surgeons, it seems might well sometimes have poor results and/or make technical errors, but the attitude to dishonesty was very different. Like Watson, neither Earlam nor Laidley took the probity of their colleagues for granted. Evidence of dishonesty was treated with a shrug and a metaphorical cold shoulder, while evidence of honesty about bad results was greeted with warm approbation. For instance Earlam was clearly favourably impressed with Californian urologist Irving Wills, and described him as: a very likeable approachable fellow about 40, I should say very sound and perfectly honest in his statements about his own mortality [rates] and his unsatisfactory results.244 Whilst they were in London, both Earlam and Laidley visited Irish urologist Terence Millin. Like American urologist Fred Foley, Millin was particularly innovative and much admired by Earlam and Laidley. Several of the diary entries indicate that he discussed with them the reliability of surgical results, as reported in public or in print, and it is clear that Millin was not always convinced that results were accurately reported. For instance, he told Laidley that one London urologist: is getting postoperative stricture though he denies in public that he does so. Millin has seen 2 cases already of his.245 In other words, two patients had consulted Millin about a problem resulting from surgery performed by someone else. Laidley also noted that following a visit to a major clinic in America in 1937, Millin had no use for the clinic or the senior urologist there. This was on the grounds that the senior urologist denied that he was getting post-operative stricture, while later after dinner one night another member of the clinic confessed that post op. stricture was worrying them to death.246 In both these cases, it was not the incidence of the complication of urethral stricture following surgery that led to adverse comment, but the fact that the surgeons concerned lied about it. Anaesthetic deaths, deaths from post-operative infection and complications arising from objects left in the patient after surgery were all events where those involved might be called to account for their actions. But few other sorts of surgical problems made their way into the press or the courts with any frequency, although the diaries kept by Archibald Watson, Malcolm Earlam and John Laidley all make it plain that there were many, many more ways in which something could go wrong on the operating table. Sometimes the patients recovered anyway, and sometimes they did not. Operating on the human body was a complex and difficult business. When things went right, surgeons were lauded by the public as heroes. But by the turn of the century, when things went wrong there was an inclination from the courts and from the press to trust that those concerned did their best, and there was an almost fatalistic acceptance of poor outcomes. Surgeons were seldom called to account for themselves before either the court of public opinion, or the legal system of inquests and criminal prosecutions, or via civil litigation. Surgeons, however, had a much better idea than the press or public about what sorts of things could and did happen on operating tables. We should not, therefore be surprised that surgeons were the first to propose some form of regulation. They were the first to recognise that there was a problem that needed to be regulated. This is the subject of the final chapter.

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Chapter 7: The Royal Australasian College of Surgeons


This chapter examines the background to early twentieth-century self-regulation in surgery. The formation of a college of surgeons for Australia and New Zealand was the work of elite surgeons and it has been traditional to see their actions as driven by self-interest. But were attempts to restrict the performance of major surgery to specialists entirely motivated by self-interest, or is this a gross oversimplification? There is no reason to suppose that medical practitioners were not influenced by a personal or collective moral code or the good opinion of their peers. The introduction of a system of accreditation for surgeons was fostered by a small group of successful men who, among other things, wanted to discourage general practitioners from performing surgery. But while they were motivated partly by the desire to protect their own incomes, a significant number of them were also motivated by the desire to protect patients from inexperienced (and perhaps unscrupulous) operators. According to Leo Kenny, the first secretary of the Royal Australasian College of Surgeons: The College was created because leading Surgeons in Australasia were satisfied that major surgery was being attempted by numbers of legally qualified medical practitioners who were deficient in technical skill, and that many unnecessary operations were being performed because of deficient surgical judgment and, in some cases, for the sake of the operating fee.247 In other words, the idea was to dissuade those who were inexpert and deficient in judgment from performing operations. This pre-emptive move by elite surgeons towards self-regulation helped to cement their Australian and New Zealand colleagues in place at the peak (in both status and income) of the moral economy of medicine, because it fostered the public perception of surgeons as trustworthy experts.

The Royal Australasian College of Surgeons (RACS)


Both the formation of the American College of Surgeons in 1913, and of the Royal Australasian College of Surgeons in 1927 emerged from pressures to achieve professional closure. Surgeons on both sides of the Pacific set out to try and limit the amount of surgery performed by general practitioners. The arguments in favour of restricting surgery to a limited group of doctors centred around competence, but there were interesting variations in how that competence was measured. In contrast to the pattern in the United States, the system of self regulation that emerged in Australia and New Zealand followed the British practice of placing very little emphasis on technical or manual operating skills. Instead, the emphasis was on character, clinical judgment and scientific knowledge.

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The beginnings of a system of self-regulation in surgery date back to when senior surgeons in North America sought to put in place a system for discriminating between operators who were competent surgeons, and operators who were not. The American College of Surgeons was founded in 1913 by Franklin Martin and others, and initially it essentially recognised and admitted to Fellowship the existing body of full time practising surgeons. However, in the 1920s and 1930s, Americans developed a pattern of accreditation, where members of each surgical specialty (ophthalmology, orthopaedics, urology etc.) could apply for accreditation by a dedicated specialty board.248 In 1924, Franklin Martin and William Mayo visited Australia and New Zealand and had an important influence on the founding of what became known as the Royal Australasian College of Surgeons.249 The seminal idea for an organisation of Australasian surgeons came from a New Zealander, Sir Louis Barnett, and the idea was floated by a Victorian, Hamilton Russell, under the umbrella of a conference of the British Medical Association meeting in Brisbane in 1920. At the time, there was considerable opposition to the founding of an Australasian body separate from the British Medical Association, including from two men who subsequently became great supporters of the College: Robert Gordon Craig from Sydney and Sir George Syme from Melbourne. However, after the visit of Mayo and Martin in 1924, Hugh Devine, a Melbourne surgeon of a somewhat younger generation, became enthusiastic about the idea. He then managed to persuade Sir George Syme to change his mind. As Syme put it in 1928, one of the reasons why: those who opposed the independent formation of the College in 1920, changed their minds was that they had become more and more convinced of the harm that was being done by the extensive performance of operations by insufficiently trained operators [with] disastrous results250 Syme, who was chosen as the inaugural president of what was initially called the College of Surgeons of Australasia, also came to the view that: if something was not done to establish an Australasian College, the American College would acquire a footing in Australasia and carry out what we were failing to do.251 Australasian surgeons might admire American surgery, and surgeons, (especially those who had been to America to see for themselves) but the allegiance to Britain was never in question. Hamilton Russell, in his address to the first Annual Meeting of the College in Canberra in 1928 noted: This great adventure of ours is the first of its kind to be embarked upon by members of the British family who have left the household of the Motherland to make their homes in the distant places of the earth.252 Together with Hamilton Russell, in 1925 Devine and Syme (all three of them Victorians) set about getting support for a college. The Sydney surgeons, including Robert Gordon Craig and Professor Sandes, then moved things along and in 1926 proposed a set of aims closely modelled on those of the American College of Surgeons. In 1927, piggy backing on the BMA conference in Dunedin, a disappointingly small group from among the forty-one surgeons who had agreed to be Founders met and elected their first Council and Executive.253 While professional closure was, of course, an important goal for those who founded the RACS, Sir George Syme argued that:

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It is common knowledge that in all the States many serious and difficult major operations, both in general and special surgery, are performed not as emergency, but habitually, by practitioners who do not possess the requisite qualifications and experience, and often in hospitals inadequately equipped. The public has no means whereby it can discriminate as to who are adequately qualified and experienced surgeons, or between hospitals that are perfectly satisfactory from a surgical point of view, and those that are not.254 Setting a bench mark for adequately qualified and experienced surgeons became the key role of the College.

Accrediting surgeons in the art and science (and craft) of surgery


In the 1930s, the Fellowship of the Royal College of Surgeons of England was widely regarded as the premier senior surgical qualification.255 It was attained only after a stiff Primary (often failed) and an equally difficult Final Examination taken one or more years later. Many aspiring surgeons sat for these examinations several times. The Old Boys column of the Melbourne Medical Students Society magazine made this quite plain. Research at the College of Surgeons [of England]. Regular attendant at Primary exams. Always hopeful. Was one entry. Only one of Melbourne bunch to pass December Primary, noted another.256 Despite this, it was generally accepted that it was possible to hold the FRCS Eng without much practical experience as a surgeon. Fellowship first go was the triumphant entry from one Melbourne graduate, Now learning to be a surgeon at the Royal Northern.257 The English fellowship was widely regarded among surgeons as a qualification for entry to the training process rather than a mark of completion of training. In contrast, the Fellowship of the American College of Surgeons marked a certain level of competence among practicing surgeons. It certainly did not mark any level of academic attainment. During the 1920s and 1930s, leaders of the infant Australasian college tried to work out what the qualifications for fellowship of their college should be. Was the American model of practical experience appropriate, or the British model of an examination? By the mid1930s, the Australasians had chosen to emphasise the importance of passing examinations in the science of surgery, rather than practical manual skills. They opted to recognise a range of academic senior surgical qualifications (especially the fellowships of the British colleges), but they did try to ensure that practical competence was acquired during a period of more or less informal and unexamined post-graduate surgical apprenticeship. Before 1932, the Fellowship of the Royal College of Surgeons of Australasia was comparable to the Fellowship of the American College of Surgeons, but after 1932 the FRACS became something very different. In future, it was to be awarded only after considerable supervised experience, and passing a two-part academic examination (conducted by one of the bodies recognized by the RACS), and passing a viva voce examination. In other words, unlike the FRCS Eng, it was to be an exit qualification at the end of training.

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In his presidential address to the American Surgical Association in 1935, Edward Archibald compared the training of surgeons in Britain, his native Canada, the United States, Australia, Germany and France. He described the fellowships of the various British colleges of surgeons as setting high academic standards, but providing no evidence of operative competence. He considered the standard set by the American College of Surgeons to be too low, although he was in favour of the emphasis on character and operative experience. He considered the French qualification too exclusive and although he was impressed with the German qualification, his clear preference was for the Australian system, which called for: A good practical knowledge of the basic sciences, including surgical pathology, and a relatively long apprenticeship under the direct supervision of a surgeon of unquestioned authority ought to constitute the essentials of the training of a real surgeon.258 At the time that he made this speech, Professor Archibald and his wife had just returned from attending the opening of the new Royal Australasian College of Surgeons building on Spring Street in Melbourne on 4 March 1935. While there, Professor and Mrs Archibald had been among a select group of guests at a round of parties hosted by Mrs Hugh Devine, Mrs Alan Newton, Lady Newland, Mrs Victor Hurley and Mrs Bernard Zwar. Their fellow guests included Sir Holburt Waring (President of the RCS of England), Dr Donald Balfour (President of the American College of Surgeons) and his wife and professors of surgery from Edinburgh and South Africa. This visit of the presidents of the American and English colleges of surgeons, and the President of the American Surgical Association, and their wives, to Australia in 1935 illustrates the nature of the international intellectual and social community of surgery, with its typical mix of the professional and the social. Members of the Englishspeaking elites knew each other personally, as well as reading reports of each others work in print. This was a hierarchical world in which events in post-colonial centres were peripheral to events in London or Baltimore, but while Australia and New Zealand were well down the hierarchy, they were never the less inextricably a part of it. Although Alan Newton and Hugh Devine wanted the RACS to hold its own examinations, it did not do so until after World War II. Instead, the RACS recognised two-part examinations conducted by other bodies, especially, the Royal College of Surgeons of England. In the 1930s, the English College periodically sent examiners for its Primary out to Australia and New Zealand. The first Australasian Final was not held until 1946 and the first Australasian Primary in 1950. These examinations were very much modelled on the format devised by the Royal College of Surgeons England and made no attempt to assess competence in the practical hands on craft of surgery. This relative neglect of the manual craft of surgery strikes the lay observer as odd. But in a 1937 article entitled The complete surgeon, New Zealand surgeon James Elliott reported John Hunter as saying that a good carpenter could be taught to operate.259 Other surgeons were fond of quoting the adage that you can teach a monkey to operate, and this kind of attitude to technical competence is consistent with the ideas expressed in the surgical diaries

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discussed in the last chapter. Although young surgeons could and did take steps to learn the manual skills involved in new surgical procedures relatively rapidly, in the 1930s few senior surgeons emphasised the importance of such manual skills.260 On the contrary, it was common for general surgeons in particular to point out that operative competence alone did not make a good surgeon: The training of the young surgeon should be on two main lines. First, and most important, is that of clinical experience, clinical observation and deduction, observation of post-operative results and the correlation of the whole in one setting. The other sidethat of the operation itselfthough important, should be looked upon only as an incident in the whole course of the case, and should not be the climax often staged to be a striking spectacle to the uncritical.261 Instead, there was an emphasis on the lengthy experience needed to acquire sound clinical judgment. The message was that manual dexterity alone might make an operator, but it did not make a surgeon. It must be recognised that the surgeon of today is not a mere craftsman [wrote Sir George Syme]. He ought to be a scientist, versed in physiology and biochemistry, pathology and bacteriology, as well as anatomy. He ought to possess judgement, derived from experience, as well as technical skill.262 It is almost as if surgeons of this era were prejudiced against attaching too much importance to technical competence. Honesty, clinical judgment, a sound grasp of the science behind their surgery and the constant pursuit of better outcomes for the patient, were the qualities that they valued most.

The Exordium
Sir George Syme argued that: The aim of the College [is] to promote the art and science of surgery, to use the words of the Charter of the Royal College of Surgeons of England, and in so doing to enable the public to get better surgical service.263 Many general practitioners, however, took the view that the College was formed to try and stop them performing major surgery, and by and large they were correct. Initially, the College adopted a group of aims closely modelled on those of the American College of Surgeons. These were set out in the Exordium, which means, according to the Shorter Oxford Dictionary, the beginning of anything, especially the introductory part of a discourse or treatise. Clause 5 of the Exordium proposed that: the public should be educated to recognise that the practice of Surgery demands adequate and special training.264 This turned out to be a highly controversial clause, which provoked anger from many general practitioners. The GPs regarded it as the result of American influence (which it was), and argued that it called for advertising. As has already been noted, advertising was strictly against the code of ethical practices for doctors, as policed by the British Medical Association (BMA) and its Australian

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and New Zealand branches. Codes of behaviour that forbade advertising were seen in the 1920s as intimately linked with trust: There is only one admissible method of advertisement open to a medical practitionerthe performance of good work, [wrote the editor of the Medical Journal of Australia in 1921.] The patient trusts the doctor with confidences of a most intimate nature he trusts him with his life and he trusts him with what is almost a blank cheque. In these circumstances the medical profession has from time immemorial required its members to obey certain ethical rules, so that implicit trust may not be misplaced and so that the honour of the profession may be maintained.265 Codes of behaviour of this kind have long been recognised as one of the strategies adopted by the professions in order to claim special status.266 But the main point of Clause 5 of the Exordium was not to overturn proscriptions against advertising, or to participate in a struggle that had recently taken place in England between those doctors who thought educating the public through the press was acceptable, and those who thought it was not.267 Rather, the clause assumed that the standard medical degree of Bachelor of Medicine and Bachelor of Surgery (MBBS) did not qualify a doctor to perform surgery. Legally, as Kenny pointed out, general practitioners could operate, but technically, it was argued, they might be deficient in skill, and they might also be deficient in surgical judgment. Clause 5 of the Exordium became the focus of the row between GPs and surgeons over the need for and role of a college of surgeons.268 The College of Surgeons agreed that the BMA should represent the profession as a whole over questions of medical politics. But this was a hollow victory for the GPs, in that it made it easier for the College to take the high moral ground and appear to be above politics and acting in the public interest. This helped the College achieve its primary aim of stopping GPs performing major surgery. The College appeared to lose the battle over the Exordium, but in fact it was more of a strategic retreat, and eventually, the College won the war. By 1932, the new generation of medical students was already taking it for granted that becoming a surgeon required both a specialist qualification and specialist experience. The Australian Medical Association (which replaced the Australian branch of the BMA from 1962) did not formally acknowledge that surgery required specialist qualification until 1965, but by then most general practitioners performed only minor surgical procedures, except under special circumstancesin emergencies or in remote areas, for instance. Although the clause of the Exordium on the need to educate the public was dropped, effectively the public (and the medical profession) did come to recognise that the practice of Surgery demands adequate and special training, and that not all doctors were equal. In the process, the RACS pulled off a public relations triumph, whereby it distanced itself from the BMA, with its trade union associations, and came to be seen as representing high surgical standards, rather than the selfish interests of surgeons. This was the real struggle within the profession, and within a decade of the formation of the College, the surgeons had won. This triumph was achieved, at least partly, through public ceremonies and an emphasis on links with British traditions.

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Rituals, Rhetoric and the Moral Economy of Medicine


In the 1920s in Australia and New Zealand, it was not uncommon to find articles in the popular press which indicated a distrust of the commercial motives behind the performance of surgical procedures. In striking contrast, by the mid1930s the popular press was enthusiastically reporting dignified ceremonies and the visits of elite surgeons from overseas, whilst representing surgeons as dedicated to the pursuit of better results for their patients. This section outlines some of the reasons for this important shift in the representation of surgeons, and the associated increase in trust and confidence in surgery. In Britain, Australia and New Zealand, a notable feature of the codes of behaviour espoused by doctors in the 1920s and 1930s was the importance attached to unpaid work by senior specialists in public hospitals. As has already been noted, surgeons and physicians with honorary hospital appointments worked within a moral economy characterized by gift exchange, with a public emphasis on honorary rather than financial rewards, including knighthoods. In a referral-based system of specialisation, the public reputation of surgery as a whole was important, but individual surgeons did not need to advertise directly to patients. Financial success depended on referrals from other doctors. Honorary public hospital appointments, a resource from which general practitioners were largely excluded, allowed specialists to establish their reputations with their peers as appropriately moral and expert practitioners. Financial success in private practice was thus linked to a public persona associated with unpaid work within the moral economy of medicine. In theory, the formation of the RACS might be assumed to have resulted in greater trust in surgeons on the grounds that there was now some benchmark of technical competence. In practice, the formation of the RACS does seem to have been associated with increasing levels of trust, but in the good intentions as well as in the competence of surgeons. However, as will be shown, that increase in trust seems to have been linked more to the public relations triumph of the ceremonies devised for the RACS in the 1930s, rather than to any real or perceived formalisation of accreditation. Immediately after the first annual meeting of the infant College of Surgeons in Canberra, the headline in the Sunday Times (Canberra) on 22 April 1928 was Surgeons and their still-born College. Farcical attempt to Corner Sawbones Market, it continued, Catholic Physicians Monopoly in Melbourne; Protestant Doctors in Control in Sydney, B. M. A. Beams on Questionable Practices. The second annual meeting in Sydney also attracted adverse publicity: Surgeons met in secret to discuss shearing the lambs; Splitting fees, ran the headline in the Daily Guardian, Sydney, in March 1929. In profound secrecy the Australian College of Surgeons is sitting somewhere in Sydney to discuss appendix-snooping, snaring the tonsil, dissection of the pay-roll, and other subjects dear to the top-notch sawbones. While the influence of these newspapers in Canberra and Sydney respectively may have been limited, the anti-surgeon attitudes are quite striking. Fee splitting (where a GP referred a patient to a specialist and they divided the fee between them) was strongly opposed as unethical by

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the College of Surgeons, but the issue had the effect of bringing doctors as a whole into disrepute. Missing the nuances of exactly who was opposing what, some newspapers simply focused on unethical behaviour by doctors. It is not overstating the case to say that certain physicians are sharing a patients tonsils with a friendly surgeon and unnecessary operations are advised This transfusion of cash revives a sick bank account ran an article in the Melbourne Herald on 23 March 1930. The public brawling between surgeons and general practitioners in this period has been described by Bryan Egan.269 GPs objected to the formation of the College on the grounds that the degree of Bachelor of Medicine and Bachelor of Surgery entitled all doctors to perform surgery. The resulting row did not provide the infant College with a good press. Surgeons College criticized, General Practitioners Bitter, Boosting and Superiority Complex ran a headline in the Melbourne Herald on 28 March 1930. In striking contrast, by the early 1930s, press reports on unnecessary surgery and appendix-snooping by sawbones were far outnumbered by headlines such as College of SurgeonsGratifying Progress, Achievements in Surgery, Art of the Surgeon and The Skill of Surgery.270 On 16 February 1932, the Melbourne Herald ran a small item headed Surgeons Arrive for Conference Important Meeting, Presentation of Mace Chief Ceremony. There was a photograph of Sir Henry Newland and reference to a distinguished group of men. They are members, wrote the Heralds reporter, of a profession which avoids self-advertisement, and so they will slip as quietly as possible into the citys stream. Yet for the next week, various aspects of the fifth annual meeting of the College were reported every day, often at some length and accompanied by large photographs, in every major Melbourne newspaper.271 The 1932 College meeting and the ceremonies surrounding the presentation of the Great Mace were a public relations triumph.
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On a hot summer evening in Melbourne in 1932, a gathering of hundreds of surgeons, some accompanied by their wives in evening gowns, met to watch the presentation to their five-year old college of a Great Mace. Besides the surgeons, there were hundreds of other guests, and most of the men were university graduates. The usual estimate of the number present that evening is 2000, all crowded into the mock gothic splendour of Wilson Hall at the University of Melbourne in their wing collars and white ties, wearing academic robes with the white lined hoods of law and the blue lined hoods of arts, to add to the scarlet of medicine and the pink of surgery.272 The mace was presented by C H Fagge, who was representing the Royal College of Surgeons of England, and he then gave the inaugural Syme Oration. In later notes on the history of the College, Hugh Devine (one of the key personalities behind the formation of the College) wrote: The Ritual of the Annual Meeting of the College [and] of the Syme Oration Dignity, colour, full evening and academic dress, the most formal ritual woven around and into the Syme Memorial lecture. The design was Alan Newtons who was a past master in this art. On the first occasion when he brought this into being, he surprised University academic circles. A precisely organised procession to the dais in the beautiful

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Gothic Wilson Hall. Primeval colours, university and college gowns; a measured processional marchnot a step out of place, and then a most distinguished overseas lecturer and a subject so natural, so broad, so satisfying. After this, the Syme Memorial lectures were the highlights of the College year. In most cases these orations had a social side. They brought not only the Fellows but also their wives from all over Australia and New Zealand After the lecture everybody met everybody and their [sic] was much private entertaining and fire side talks, old friends met and much swapping of surgical experience, often more illuminating and entertaining than the formal meetings and lectures These meetings raised the prestige of the profession, kept the lay world generally aware of what was going on in the College for their benefit 273 As Devine clearly understood, all the dignity, colour and most formal ritual of the annual meetings helped raise the prestige of the profession. 274 Among other things, the meetings helped shift the balance of reporting in the newspapers.275 Splendid ceremonies were given wide coverage. While articles critical of surgeons and surgery were not uncommon in the 1920s, in the 1930s they were significantly outnumbered by generally positive articles reporting on the meetings of the RACS. In particular, the inaugural ceremonies and the Syme Oration at the beginning of each annual meeting were regularly given substantial coverage, while the associated garden parties and functions featuring the wives of Fellows were reported in the social pages. Effectively, the press obligingly took on the role of educating the public to associate the practice of surgery with the Royal Australasian College of Surgeons, while giving both surgery and surgeons a positive image.
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The 1932 College meeting represented a turning point in the public image of Australian surgery. Criticism of surgeons and surgery may not have disappeared totally after 1932, but it certainly faded into the background. Year after year, the image of surgeons presented through the annual meetings was of restrained and dignified ritual. But despite this, surgeons could maintain that they were above self-advertisement. The ceremonies were seen as uncontroversial, and nothing to do with politics or with making money. In a sense, the newspaper reporters appear to have taken a certain pride in the Colorful Scene at Wilson Hall and the overseas visitors paying tribute to Australasian surgeons. David Cannadine has highlighted the importance of British royal pageantry in this era.276 George V (191036) managed to combine a respectable private life, comparable to that of his grandmother, with his fathers fondness for attention to detail in public ceremonies. Cannadine describes him as obsessed with matters such as the correct dress and manner of wearing decorations. But at the same time, his private life combined the unpretentiousness of the country gentleman with the respectability of the middle class. The result was truly popular. The monarchy came to appear as above politics and, eventually, above reproach. Cannadine argues that the restrained, anachronistic, ceremonial grandeur of the British monarchy in this period contributed much to its popularity and air of unassailable stability. But the press also played an important role. Cannadine describes the response of the media

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as sustained obsequiousness, reporting the great ceremonies of state in an awed and hushed manner.277 Restrained, anachronistic, ceremonial grandeur was precisely the tone set by the rituals devised for the RACS by Alan Newton and although the response of the press was hardly obsequious, it was generally respectful. Charles Mackay described Newton as more dignified than dignity itself, with a love for ceremonial and respect for tradition and sound lineage.278 This was the man who was master of ceremonies for the presentation of the Great Mace. Newton produced a ceremony that conferred precisely those attributes of dignity, respect for tradition and sound lineage on the infant Royal Australasian College of Surgeons. While surgery was going through a period of dramatic change and an enormously rapid increase in the number and range of operations performed, the newly invented ritual traditions gave the infant College an air of dignified stability. This was reinforced at the annual meetings by repeated public display of the links with Britain. At the twelfth annual meeting, for instance, in 1939, the principal guest was Sir Alfred Webb-Johnson, surgeon to Queen Mary. He read a message of good wishes from the Queen, and the President and Fellows of the RACS promptly cabled a reply to the effect that the Queens message would inspire them and their successors to strive in collaboration with their brethren in the Mother country to advance the knowledge of the science and art of surgery.279 The RACS, by association, borrowed the past of the British colleges of surgeons. In the process, the RACS succeeded in borrowing much of the mantle of confidence in surgery that went with the myths and traditions surrounding Harley Street surgeons. The first formal ceremonial occasion which pulled off this borrowing of British history was the presentation of the Great Mace in 1932. In 1920, Sir Berkeley Moynihan presented a ceremonial mace to the American College of Surgeons and it was Moynihan, as President of the Royal College of Surgeons of England, who first suggested the presentation of a ceremonial mace to the Australasian college.280 Both echoed the presentation of a mace to the RCS of England, as recently as 1822, by King George IV, which in turn followed a lengthy tradition of presenting maces to various organisations as a symbol of their links with/loyalty to the crown. Some ceremonies are not as old as they seem, but they may draw much of their power to reinforce the status of those involved precisely from an evocation of venerable traditions and links to a mythologised past. The idea of the gift of the Australasian mace, however, was not a spontaneous act of recognition by the RCS of England. The English college was repeatedly lobbied by key players in the founding of the Australasian College, to persuade it to acknowledge the RACS. Hamilton Russell, Sir George Syme and Hugh Devine each went to London in turn in the late 1920s.281 Finally, in 1931, the King was graciously pleased to approve the prefix Royal to the title of the College, and the College of Heralds approved a grant of arms.282 The College of Surgeons of Australasia became the Royal Australasian College of Surgeons (RACS). News of the granting of the prefix Royal and the gift of the mace reached Australia more or less at the same time, and the Australian press seized upon the story, some collapsing the two events into a single (metaphorically true) recognition of the Australasian college by the British: The King has conferred upon the College of Surgeons the prefix Royal and the president of the British [sic] Royal College, Lord Moynihan, will visit Australia in

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1932 to present the mace. Lord Moynihan is one of Englands greatest surgeons, and a brilliant orator.283 Papers as diverse as the Launceston Examiner and the Melbourne Age carried stories about the mace at the beginning of 1931, and there was a detailed description and photograph in The Times (of London). In a sense, the gift of the mace was received with pride by the public of Australia and New Zealand as well as by Australasian surgeons. Lord Moynihan to visit us ran a headline in the Daily Guardian in 1931, striking a completely different note from the appendix snooping sawbones in the same paper two years earlier. By the time the mace was presented in Wilson Hall in February 1932, and C H Fagge (literally) bade it farewell, it had been the subject of hundreds of column inches of news.284 After it was presented, the public wanted to see it, and it went on ceremonial display in art galleries in Victoria, New South Wales and New Zealand.285

Conclusion
This chapter has examined some of the attitudes which lay behind the very successful emphasis on moral qualities and scientific knowledge, rather than manual skills, as surgeons assessed each others behaviour. For many years it has been customary to see self-regulation as self-interested. There is no doubt that surgeons benefited, but setting up the Royal Australasian College of Surgeons was not, in Shaws phrase, just a conspiracy against the laity.286 Surgeons in North America, as well as in Australia and New Zealand, took steps to introduce some form of self-regulation because they were the first to recognise that there was a problem that needed to be regulated. Surgeons were in a very good position to know what sort of things could go wrong in surgery. Those who spent a part of almost every day in an operating theatre were acutely aware that operations performed by general practitioners who picked up a scalpel once or twice a month were not likely to be in the best interests of the patient. The rhetoric of putting patients first was not just rhetoric. A significant number of surgeons believed that it was the right thing to do. Their self-esteem and the impact of peer recognition depended on putting patients first, trying to improve surgical outcomes, and taking responsibility for their failures as well as their successes. The proportion of doctors who held these views was sufficiently large to make this code of behaviour credible, both with each other and with the public at large. Within surgery, the behaviour of individuals was not subject to any particular outside regulations or sanctions other than those which applied to doctors as a whole. There was a code of behaviour, mainly embedded in local mores, which subjected surgeons to peer group pressure about what sort of behaviour was appropriate and what was not. As has been argued elsewhere, early twentieth-century surgeons worked within a framework that had many of the features of a moral economy, characterised by gift exchange.287 This moral economy intersected with the logic of market forces, but the greatest rewards were knighthoods and other forms of peer recognition, not money. One of this systems greatest triumphs was to construct surgeons as trustworthy experts, above the grubby pursuit of money.

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In 1928, Sir George Syme addressed a hostile meeting of the Victorian branch of the BMA on the aims and objects of the College of Surgeons of Australasia. Many general practitioners were opposed to the formation of a college of surgeons, which they saw, correctly, as part of a move to restrict the performance of operations to full-time surgeons. Syme chose to end his address as follows: The ideal of the College of Surgeons of Australasia is to make more perfect the art of surgery and to free it from all commercialism, so that all who practice it shall give the best and most perfect service to the public. The College holds with Sir Berkeley Moynihan that: Of all the temples in the world none is more sacred than the operation theatre, that nothing base should dwell in such a temple, and as this temple waxes, the inward service of the mind and soul grows wide withal.288 There is no emphasis here on the science of surgery, let alone the craft. Syme borrowed Moynihans authority in describing operating theatres as sacred or ritual spaces, by implication unsuitable venues for performances by just any doctor.289 But above all, he chose to emphasise an anti-commercial ethic of public service. It turned out to be a winning cmbination.

EXORDIUM. Whereas it is advisable, in the interests both of the peoples of Australia and New Zealand, and of those who practise the profession of Surgery in these countries, that
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1. the high traditions of that profession should be upheld and developed, 2. the intensive study of the science and art of Surgery, and the extension of surgical knowledge by means of research should be promoted, 3. facilities should be provided for the higher education and advanced technical training of surgeons and surgical specialists, 4. a high standard of moral conduct should be demanded from all who accept the responsibilities of a surgeon, in their relations with patients and members of the medical profession, 5. the public should be educated to recognise that the practice of Surgery demands adequate and special training, 6. the standards of surgical practice in hospitals should be elevated.

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Bibliography
Archival Sources Fryer Collection, University of Queensland:

Kesteven, Hereward Leighton, Medical Memories of Yesteryear, MS F2594 Carvosso, Arthur Benjamin, Some early reminiscences, MS F2593 Brisbane Hospital Committee, Annual Reports. 18821902 and 19101916. The reports for the years 1883, 1886, 1893 and 1899 include rules and by-laws of the hospital.
Queensland State Archives, Brisbane:

Brisbane Hospital, Patient Charts 8.1.190010.5.1900, p. 992, RSI 3806 Records of Operations, Brisbane Hospital, 19221945, RSI 3807 Inquest Files, JUS series Muttaburra Hospital, Patient Admissions Records, 19291933, A/58404Z2800
Royal Australasian College of Surgeons, Melbourne, Archives:

Watson, Archibald, Diaries, Series 64 Devine, Sir Hugh Berchmans, Series 177, SB 28, SB 36, SB 106107, papers and press cuttings Register of Fellows of the College Archives of the Urological Society of Australasia: M S S Earlam and J W S Laidley, Item 78, surgical diaries 19367, 1938 and 1948
Royal Brisbane Hospital Nursing Archives:

Nursing Register, 18981901


State Library of Queensland:

Bell Family Diaries, OMF/1/10, November-December 1912 Blanchard, George, Diary 18881889, OM 824, box 9159. Clark, Bettie, Diary, 20 Jun 188219 Jan 1898, M1176/1, Box 3919 O/S. Jack, Eustace M., Formation of the [Brisbane] City Ambulance Transport Brigade, 18923, OM 6712, Box 8631. Linning, Louisa, papers, M524/2, Box 5160. Thelander, Charles Augustus, papers, OM 9514, case books, item 2/1 and item 2/2. Harris, William, Police Magistrate, Report of the Royal Commission appointed to Inquire into and Report upon the Death of Thomas Flynn, in the Brisbane General Hospital, on the 22nd October, 1930 (Brisbane: Government Printer, 1931).
State Library of Victoria:

Hastings, William, Diaries, 1880; 18834; 18845; 18868; 188990; 189092; 1894 7; originals, La Trobe collection MS8919, B445; Warragul Historical Society; copies Melbourne Hospital, Report of the Committee of Management, with statement of accounts, list of subscribers and donors and statistical returns, 1902/31933/4 Annual Reports, St Vincents Hospital Melbourne, 1893/41934/5 The Hornsby and District Hospital Annual report for the Year Ending 30th June 1939 Sixty-First Annual Report of the Managers of the Alfred Hospi-

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tal and a List of Subscriptions and Donations, 1931


St Vincents Hospital Archives, Melbourne:

Surgeons Case Books


University College Hospital, London, Archives.

St Peters Hospital for Stone, Surgical records


Published Sources Journals:

Australian & New Zealand Journal of Surgery Australasian Medical Gazette British Medical Journal (BMJ) Intercolonial Medical Congress of Australasia, Transactions Intercolonial Medical Journal of Australasia Journal of the College of Surgeons of Australasia Lancet Medical Journal of Australia (MJA) Speculum
Books and articles:

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Ackerknecht , Erwin, Medicine at the Paris Hospital, 17941848 (Baltimore: Johns Hopkins University Press, 1967). Adams, Annmarie, Architecture in the Family Way, Doctors, Houses, and Women, 18701900 (Montreal: McGill-Queens University Press, 1996). Adams, Annmarie and Thomas Schlich, Design for Control: Surgery, Science and Space at the Royal Victoria Hospital, Montreal, 18931956, Medical History, 2006, 50:303324. Ahern, M. M. & M. S. Hendryx, Social capital and trust in providers, Social Science & Medicine, 2003, 57:11951203. Andermann, Anne Adina, Physicians, fads and pharmaceuticals: a history of aspirin, Crossroads: where medicine and humanities meet, McGill University www.medicine.mcgill.ca/mjm/issues/c02n02/aspirin.html accessed 22.2.08. Apple, Rima D., Constructing Mothers: Scientific Motherhood in the Nineteenth and Twentieth Centuries, Social History of Medicine, 1995, 161178. Armstrong, David, A New History of Identity, A Sociology of Medical Knowledge (Basingstoke: Palgrave, 2002). Arnup, Katherine, Andre Levsque, and Ruth Roach Pierson, eds., Delivering Motherhood, Maternal Ideologies and Practices in the 19th and 20th Centuries (London: Routledge, 1990). Attwood, H., James A. Gillespie and M. Lewis, eds, New Perspectives on the History of Medicine (Melbourne: 1990). Baker, Robert, The History of Medical Ethics, in W.F. Bynum and Roy Porter, eds, Companion encyclopedia of the history of medicine, vol 2 (London: Routledge, 1993), pp. 852887. Baker, Robert, Dorothy Porter and Roy Porter, eds, The Codification of Medical Morality, historical and philosophical studies of the formalization of Western medical morality in the eighteenth and nineteenth centuries, volume one: medical ethics and etiquette in the eighteenth century (Dordrecht: Kluwer academic publishers, 1993). Bamji, A., Sir Harold Gillies: surgical pioneer, Trauma, 2006, 8: 143156.

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

113

Download free from www.thehistoryofsurgery.com

Barry, Hugh, Orthopaedics in Australia. The History of the Australian Orthopaedic Association (Sydney: Australian Orthopaedic Association, 1983). Bashford, Alison, Purity and Pollution : Gender, Embodiment and Victorian Medicine (St Martins Press, New York, 1998). Modernity, gender and the negotiation of science in Australian nursing, 18801910, Journal of Womens History, 2000, 12: 127146. Beasley, A W, The Mantle of Surgery, The First Seventy-Five Years of the Royal Australasian College of Surgeons (Melbourne: RACS, 2002). Biagioli, Mario, Galileo, Courtier, The Practice of Science in the Culture of Absolutism (Chicago: The University of Chicago Press, 1993). Tacit Knowledge, Courtliness, and the Scientists Body, in Choreographing History, Susan Leigh Foster, ed., (Bloomington: Indiana University Press, 1995), 6981. Bideau, Alain, Bertrand Desjardins, and Hctor Prez Brignoli, eds., Infant and Child Mortality in the Past (Oxford: Clarendon Press, 1997). Bijker, Wiebe E., Of Bicycles, Bakelites, and Bulbs, Toward a Theory of Sociotechnical Change (Cambridge, Mass.: The MIT Press, 1995). Bijker, Wiebe E., Thomas P. Hughes and Trevor Pinch, eds, The Social Construction of Technological Systems; New Directions in the Sociology and History of Technology (Cambridge, Mass.: The MIT Press, 1987); Bijker, Wiebe E. and John Law, eds, Shaping Technology/Building Society; Studies in Sociotechnical Change (Cambridge, Mass.: The MIT Press, 1994). Blandy, John and John S. P. Lumley, eds., The Royal College of Surgeons of England 200 Years of History at the Millennium (London: The Royal College of Surgeons of England and Blackwell Science, 2000). Boreham, Peter, Surgical Journeys, A History of the Surgical Union which became the 1921 Surgical Travelling Club of Great Britain (Devon: Merlin Books, 1990). Bosk, Charles L., Forgive and Remember; Managing Medical Failure (Chicago: University of Chicago Press, 1979). Bourdieu, Pierre, Distinction, A Social Critique of the Judgement of Taste, trans. Richard Nice (London: Routledge, 1984), (1st pub. Paris, 1979). The Field of Cultural Production (Cambridge: Polity Press, 1993). Outline of a Theory of Practice (Cambridge: Cambridge University Press, 1999); Bourke, Joanna, The battle of the Limbs: amputation, artificial limbs and the Great War in Australia, Australian Historical Studies, 1998, 110: 4967. Bradshaw, Ann, The Nurse Apprentice, 18601977 (Aldershot: Ashgate, 2001). Brennan, T A, L L Leape, N M Laird, et al. Incidence of adverse events and negligence in hospitalized patients: Results from the Harvard Medical Practice Study I, New England J. Med, 1991, 324:370376. Brieger, Gert H., Surgery, in Ronald L. Numbers, ed., The Education of American Physicians (Berkeley: University of California Press, 1980). Brown, E R, Rockefeller Medicine Men, Medicine and Capitalism in America (Berkeley, University of California Press, 1979). Brunton, Deborah, The rise of laboratory medicine, in Deborah Brunton, ed., Medicine Transformed, pp.92118. Burch, Druin, Digging up the Dead, Uncovering the Life and Times of an Extraordinary Surgeon (London: Chatto & Windus, 2007). Burney, Ian A, Bodies of Evidence, Medicine and the Politics of the English In-

114

Download free from www.thehistoryofsurgery.com

quest, 18301926 (Baltimore: Johns Hopkins University Press, 2000). Anaesthesia and the evaluation of surgical risk in mid-nineteenthcentury Britain, in Thomas Schlich and Ulrich Trhler, eds, The Risks of Medical Innovation (London: Routledge, 2006), pp. 3852. Bynum, W F, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). Bynum, W F, Anne Hardy, Stephen Jacyna, Christopher Lawrence and Tilli Tansey, The Western Medical Tradition 18002000 (Cambridge: Cambridge University Press, 2006). Byrne, W S, Caesarean Section (Sanger-Leopold Operation), The Australasian Medical Gazette, 1892, 11: 147149. Callister, Sandy, Broken gargoyles: the photographic representation of severely wounded New Zealand soldiers, Social History of Medicine, 2007, 20: 111130. Cannadine, David, Splendor out of Court: Royal Spectacle and Pageantry in Modern Britain, c. 18201977, in Sean Wilentz, ed., Rites of Power: Symbolism, Ritual and Politics Since the Middle Ages (Philadelphia: University of Philadelphia Press, 1985). Carless, Albert, Manual of Surgery (Rose and Carless) for students and practitioners, tenth edition (London: Bailliere, Tindall and Cox, 1921). Carrier, James G., Gifts and Commodities, Exchange and Western Capitalism since 1700 (London: Routledge, 1995). Carter, Jennifer M T, Painting the Islands Vermillion; Archibald Watson and the Brig Carl (Melbourne: Melbourne University Press, 1999). Carter, K. Codell, Kochs postulates in relation to the work of Jacob Henle and Edwin Klebs, Medical History, 1985, 29:353374. Cassell, Joan, On Control, Certitude, and the Paranoia of Surgeons, Culture, Medicine and Psychiatry, 1987, 11: 229249. The Woman in the Surgeons Body (Cambridge, Mass.: Harvard University Press, 1998); Cathell, D W, Book on the physician himself and things that concern his reputation and success (Philadelphia: F. A. Davis, 1890) 9th edition; Cavenagh-Mainwaring, W, Rupture of the vaginal wall, Aus Med Gaz, 1900, 19:1478. Chambers, David Wade and Richard Gillespie, Locality in the History of Science; Colonial Science, Technoscience, and Indigenous Knowledge, Osiris, 2000, 15:221240. Chambers, David Wade, Does distance tyrannize science? in R. W. Home and Sally Gregory Kohlstedt, eds, International Science and National Scientific Identity, Australia Between Britain and America (Dordrecht: Kluwer Academic Publishers, 1991). Locality and Science: Myths of Centre and Periphery, in A. Lafuente, A. Elena and M. L. Ortega, eds, Mundializacion de la ciencia y cultura nacional, Actas del Congreso Internacional <Ciencia, descubrimiento y mundo colonial> (Madrid: Doce Calles, 1993). Chatfield, Florence, Obituary, Ernest Sandford Jackson, Medical Journal of Australia, 1938, II:65960. Closs, J O, Hypertrophy of the prostate, Transactions of the fourth session of the Intercolonial Medical Congress of Australasia, 1896, Dunedin (Dunedin: Otago Daily Times, 1896), 191198. Cochrane, A L, Effectiveness and Efficiency: random reflections on health services (London: Nuffield Provincial Hospitals Trust, 1972). Collins, H M, The TEA Set: tacit Knowledge and Scientific Networks, Science Studies, 1974, 4: 16586. Dissecting Surgery: Forms of Life Depersonalized, Social Studies of Science, 1994, 24: 31133.

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

115

Download free from www.thehistoryofsurgery.com

Cooter, Roger, The meaning of fractures: orthopaedics and the reform of British hospitals in the inter-war period, Medical History, 1987, 31: 306332. Surgery and Society in Peace and War, Orthopaedics and the Organisation of Modern Medicine, 18801948 (Basingstoke: Macmillan, 1993). Cooter, Roger and Bill Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997). Corbin, Alain, The Foul and the Fragrant : Odor and the French Social Iimagination (Cambridge, Mass.: Harvard University Press, 1986). Cortiula, Mark W, Serum and Soluvac: the Australian approach to whole blood transfusion during the Second World War, Journal of the History of Medicine & Allied Sciences, 1999, 54: 413438. Cowlishaw, L, The History and Origin of the Royal College of Surgeons in Ireland, Journal of the College of Surgeons of Australasia 1 (1928): 2125. Cramond, Tess, Lilian Violet Cooper, MD, FRACS, Foundation Fellow, Royal Australasian College of Surgeons, Australian and New Zealand Journal of Surgery, 1993, 63:134142. Crenner, Christopher, Private Practice in the Early Twentieth-Century Medical Office of Dr. Richard Cabot (Baltimore: Johns Hopkins University Press, 2005). Crowther, Anne and Marguerite Dupree, The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century, Bulletin of the History of Medicine,1996, 70(3):387413. Crowther, W E L H, A background to medical practice and the training of surgical apprentices and pupils in Van Diemans Land, Australian and New Zealand Journal of Surgery, 1952, 21: 185200. Curtis, Stephan M, Nutrition and scarlet fever mortality during the epidemics of 186090: the Sundsvall Region, Social History of Medicine, 2004, 17: 199221. Cunningham, Andrew, Transforming plague: the laboratory and the identity of infectious disease, in Cunningham & Williams, eds, Laboratory Revolution, pp. 209244. Cunningham, Andrew and P. Williams, eds, The Laboratory Revolution in Medicine (Cambridge: Cambridge University Press, 1992). Dally, Ann, Women Under the Knife, A History of Surgery (New York: Routledge, 1992). Daston, L, The Moral Economy of Science, Osiris, 1995, 10:324. Davidson, G M, Some experiences of prostatic surgery in a provincial city: a report of one hundred and nine cases, Medical Journal of Australia, 1938, I: 611619. Davis, Loyal, Fellowship of Surgeons A history of the American College of Surgeons (Springfield: Charles C. Thomas, 1966). Devine, Hugh Berchmans, Surgical Judgement, Australian and New Zealand Journal of Surgery, 1950, 20: 161. Digby, Anne, Making a Medical Living: Doctors and Patients in the English Market, 17201911 (Cambridge: Cambridge University Press, 1994). The Evolution of the British General Practitioner 1850 1948 (Oxford: Oxford University Press, 1999). Duncan, R B, The Radical Cure of Inguinal Hernia, Intercolonial Medical Journal of Australasia, 1900, 5(1): 387395. Dyason, Diana, William Gillbee and Erysipelas at the Melbourne Hospital, Journal of Australian Studies, 1984, 14: 328. The medical profession in colonial Victoria, 18341901, in Roy Macleod and Milton Lewis, eds, Disease, Medicine and Empire (London: Routledge, 1988), pp 194216.

116

Download free from www.thehistoryofsurgery.com

Earlam, M S S, Robert Gordon Craig, Proceedings of the Urological Society of Australasia, 1957. Bryan Egan, Ways of a Hospital. St Vincents Hospital Melbourne, 1890s1990s (St Leonards: Allen and Unwin, 1993). Egan, Bryan, Specialization, Surgery and the Sydney Bulletin, Australian and New Zealand Journal of Surgery, 1988, 58: 983987. Ellis, Robert, The Asylum, the Poor Law, and a Reassessment of the FourShilling Grant: Admissions to the County Asylums of Yorkshire in the Nineteenth Century, Social History of Medicine, 2006, 19(1):5571. Elmslie, R G, Mrs-L case a celebrated South Australian surgical case, Australian and New Zealand Journal of Surgery, 1991, 61: 780788. Ernst, Waltraud, ed., Plural Medicine, Tradition and Modernity, 18002000 (London: Routledge, 2002). Ewing, Maurice, A place in posterity, Australian and New Zealand Journal of Surgery, 1977, 47: 531588. Felker, Marcia Elliott, Ideology and Order in the Operating Room, in Lola RomanucciRoss, Daniel E Moerman and Laurence R Tancredi, eds, The Anthropology of Medicine, From Culture to Method (Massachusetts: Bergin & Garvery Publishers Inc., 1983), 349365. Ferguson, Moira, Animal Advocacy and Englishwomen, 17801900 (Ann Arbor: University of Michigan Press, 1997). Finch, Lynette, Soothing Syrups and Teething Powders: Regulating Proprietary Drugs in Australia, 18601910, Medical History, 1999, 43:7494. Fison, D C, The History of Royal Childrens Hospital, Brisbane, Medical Journal of Australia, 1969, I: 417422. Fleck, Ludwig, Genesis and Development of a Scientific Fact, trans. Fred Bradley and Thaddeus J. Trem (Chicago: University of Chicago Press, 1979). Forrester, John M, The Origins and Fate of James Curries Cold Water Treatment for Fever, Medical History, 2000, 44:5774. Foucault, Michel, (1963). The Birth of the Clinic, An Archaeology of Medical Perception (London: Routledge, 2003). Fox, Nicholas J, The Social Meaning of Surgery (Milton Keynes: Open University Press, 1992). Discourse, organisation and the surgical ward round, Sociology of Health and Illness, 1993, 15: 1642. Space, Sterility and Surgery: Circuits of Hygiene in the Operating Theatre, Social Science and Medicine, 1997, 45: 649657. Fox, Renee and Judith P. Swazey, The Courage to Fail, A Social View of Organ Transplants and Dialysis (Chicago: The University of Chicago Press, 1974). Francis, Alexander, Then and Now, The Story of a Queenslander (London: Chapman and Hall, 1935). Frey, B S, Motivation and Human Behaviour, in P. Taylor-Gooby, ed., Risk, Trust and Welfare (Basingstoke: Macmillan Press, 2000), pp. 3150. Freidson, Eliot, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970). Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970). Friedman, Steven, A History of Vascular Surgery (Malden: Blackwell, 2005). Fukuyama, F, Trust, The Social Virtues and the Creation of Prosperity (London: Penguin, 1995). Fullerton, Alex Young, A Case of Acute Intestinal ObstructionOpera-

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

117

Download free from www.thehistoryofsurgery.com

tionRecovery, The Australasian Medical Gazette, April 20, 1900, XIX. Gaw, Jerry L, A Time to Heal: The Diffusion of Listerism in Victorian Britain (Philadelphia: American Philosophical Society, 1999). Geary, Laurence M, The Scottish-Australian Connection 18501900, in Vivian Nutton and Roy Porter, eds, The History of Medical Education in Britain, (Amsterdam: Rodopi, 1995). Gibson, J. Lockhart, Removal of adenoid growths from the naso-pharynx, Intercolonial Quarterly Journal of Medicine and Surgery, 18956, II: 223231. Excision of enlarged right lobe and isthmus of thyroid gland, Intercolonial Quarterly Journal of Medicine and Surgery, 18956, 2:6069. Gillespie, James, The Price of Health: Australian Governments and Medical Politics 19101960 (Melbourne: Cambridge University Press, 1991). Gillett, Margaret, Dear Grace, A Romance of History (Melbourne: Melbourne University Press, 1986). Gillies, H D, W K Fry, H Wade, Plastic Surgery of the Face: Based on Selected Cases of War Injuries of the Face Including Burns (Frowde: Hodder and Stoughton, 1920). Gillis, Jonathan, The history of the patient history since 1850, Bulletin of the History of Medicine, 2006, 80:490512. Gilson, L, Trust and the development of health care as a social institution, Soc. Sci. & Med., 2003, 56:14531468 p. 1457. Godden, Judith, Lucy Osburn, a Lady Displaced, Florence Nightingales Envoy to Australia (Sydney: Sydney University Press, 2007). Gradmann, Christopher, Robert Koch and the pressures of scientific research: tuberculosis and tuberculin, Medical History, 2001, 45: 132. Granshaw, Lindsay, Upon this principle I have based a practice: the development and reception of antisepsis in Britain, 186790, in John V. Pickstone, ed., Medical Innovations in Historical Perspective (Basingstoke: Macmillan, 1992). Granshaw, Lindsay and Roy Porter, ed., The Hospital in History (London: Routledge, 1989). Green, David and Lawrence Cromwell, Mutual Aid or Welfare State, Australias Friendly Societies (Hemel Hempstead: George Allen & Unwin, 1984). Greene, Jeremy A, Therapeutic infidelities: noncompliance enters the medical literature, 19551975, Social History of Medicine, 2004, 17: 327343. Greenwood, Anna, Lawson Tait and Opposition to Germ Theory: Defining Science in Surgical Practice, Journal of the History of Medicine, 1998, 53:9913. Gregory, Alan, The Ever Open Door: A History of the Royal Melbourne Hospital (Melbourne: Hyland House, 1998). Gregory, Helen, A Tradition of Care, A History of Nursing at the Royal Brisbane Hospital (Brisbane: Boolarong Publications, 1988). Nurse training comes to town, in Brisbane History Group, Brisbane in 1888, the Historical Perspective (Brisbane, 1988), pp.8395. Gregory, Helen and Cecilia Brazil, Bearers of the Tradition: Nurses of the Royal Brisbane Hospital 18881993 (Brisbane: Boolarong Publications, 1993). Grob, Gerald N, The rise and decline of tonsillectomy in twentieth-century America, Journal of the History of Medicine and Allied Sciences, 2007, 62: 383421. Guerrini, Anita, Experimenting with Humans and Animals (Baltimore: Johns Hopkins University Press, 2003). Gugliotta, Angela, Dr. Sharp with his little knife: therapeutic and punitive origins of eugenic vasectomyIndiana, 18921921, Journal of

118

Download free from www.thehistoryofsurgery.com

the History of Medicine & Allied Sciences, 1998, 53: 371406. Haakonssen, Lisbeth, Medicine and Morals in the Enlightenment: John Gregory, Thomas Percival and Benjamin Rush, Clio Medica 44 (Amsterdam: Rodopi, 1997). Hagstrom, Warren O, Gift giving as an organising principle in science (1965), in Barrry Barnes and David Edge, eds, Science in Context: Readings in the Sociology of Science (Milton Keynes: Open University Press, 1982), 2134. Haines, Michael R, Socio-economic differentials in infant and child mortality during mortality decline: England and Wales, 18901911, Population Studies, 1995, 49: 297315. Haines, Robin, Doctors at Sea, Emigrant Voyages to Colonial Australia (Basingstoke: Palgrave Macmillan, 2005). Hall, R. D. McKellar, Reflections of an Orthopaedic Surgeon (Victoria Park: Hesperion Press, 1983). Hamilton, David, The nineteenth-century surgical revolutionantisepsis or better nutrition? Bulletin of the History of Medicine, 1982, 56:3040. Hannaway, Caroline and Ann La Berge, eds, Constructing Paris Medicine, Clio Medica 50 (Amsterdam: Rodopi, 1998). Hardy, Anne, Tracheotomy versus intubation: surgical intervention in diphtheria in Europe and the United States, 18251930, Bulletin of the History of Medicine, 1992, 66:536559. Hardy, C H W, An extra-uterine foetation, Aus Med Gaz, 1900, 19: 2235. Hare, F E, The Cold Bath Treatment of Typhoid Fever, the experience of a consecutive series of nineteen hundred and two cases treated at the Brisbane Hospital (London: Macmillan and Co., 1898). Harley, D, Rhetoric and the Social Construction of Sickness and Healing, Social History of Medicine, 1999, 12:40735. Harris, Bernard, Public health, nutrition, and the decline of mortality: the McKeown thesis revisited, Social History of Medicine, 2004, 17: 379407. Harris, S Harry, Prostatectomy with complete closure, Journal of the College of Surgeons of Australasia, 1928, 1: 6567. Prostatectomy with complete closure, Medical Journal of Australia, 1928, II: 288. Suprapubic prostatectomy with closure, British Journal of Urology, 1929, 1: 285295. Prostatectomy with closure of the bladder, Medical Journal of Australia, 1932, II: 158. Hayter, Charles R R, The clinic as laboratory: the case of radiation therapy, 18961920, Bulletin of the History of Medicine, 1998, 72: 663688. Seeds of discord: the politics of radon therapy in Canada in the 1930s, Bulletin of the History of Medicine, 2003, 77: 75102. Heath, Christopher, ed., Dictionary of Practical Surgery by Various British Hospital Surgeons (London: Smith, Elder & Co., 1886). Herring, E Ken, Notes on diphtheria, Australasian Medical Gazette, 1901, 20: 3812. Hess, Volker, Standardizing body temperature: quantification in hospitals and daily life, 18501900, in Gerard Jorland, Annick Opinel and George Weisz, eds, Body Counts, Medical Quantification in Historical and Sociological Perspectives (Montreal: McGill-Queens University press, 2005), pp. 109126. Hicks, Neville, This Sin and Scandal, Australias Population Debate 18911911(Canberra: Australian National University Press, 1978). Hirschauer, Stefan, The Manufacture of Bodies in Surgery, Social Studies of Science, 1991, 21: 279319;

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

119

Download free from www.thehistoryofsurgery.com

The Scalpels Edge, The Culture of Surgeons (Boston: Allyn and Bacon, 1999). Hirschfeld, Eugen, The tepid bath treatment of typhoid fever, Aus Med Gaz, 1900, 19: 2225. Hobsbawm, E J and T Ranger, The Invention of Tradition (Cambridge: Cambridge University Press, 1983). Hollingsworth, J Rogers, A Political Economy of Medicine: Great Britain and the United States (Baltimore: Johns Hopkins University Press, 1986). Honigsbaum, Frank, The Division in British Medicine, A History of the separation of general practice from hospital care 19111968 (London: Kogan Page, 1979). Health, Happiness, and Security, The creation of the National Health Service (London: Routledge, 1989). Hooker, Claire and Alison Bashford, Diphtheria and Australian public health: bacteriology and its complex applications, c. 18901930, Medical History, 2002, 46:4164. Howell, Joel D, Technology in the Hospital, Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995); Hughes, J Estcourt, A History of the Royal Adelaide Hospital (Adelaide: Board of Management of the Royal Adelaide Hospital, 1967). Hurley, Victor, An outline of a suggested policy for the College of Surgeons of Australasia for the improvement of hospitals, Journal of the College of Surgeons of Australasia, 1928, 1: 4352. Illingworth, P, Trust: The Scarcest of Medical Resources, Journal of Medicine and Philosophy, 2002, 27:3146. Inglis, K S, Hospital and Community, A History of the Royal Melbourne Hospital (Melbourne: Melbourne University Press, 1958). Jackson, E Sandford, An Address, MJA, 1926, II:855861. Jacob, Margaret C and Michael J Sauter, Why did Humphrey Davy and associates not pursue the pain-alleviating effects of nitrous oxide? Journal of the History of Medicine, 2002, 57: 161176. Jacyna, L S, The localisation of disease, in Deborah Brunton ed., Medicine Transformed, Health, Disease and Society in Europe 18001930 (Manchester: Manchester University Press/Open University, 2004), pp130. Jewson, N, The Disappearance of the Sick Man from Medical Cosmology, 17701870, Sociology, 1976, 10: 22544. Jones, Ross L, Humanitys Mirror, 150 Years of Anatomy in Melbourne ((Melbourne: Haddington Press, 2007). Jordanova, Ludmilla, Sexual Visions; Images of Gender in Science and Medicine between the Eighteenth and Twentieth Centuries (Madison: University of Wisconsin Press, 1989). Kaa, D J van de, Anchored narratives: the story and findings of half a century of research into the determinants of fertility, Populations Studies, 1996, 50: 389342. Katz, Pearl, Ritual in the Operating Room, Ethnology, 1981, 20: 33550. Kaye, Geoffrey, Observations on anaesthesia in cerebral surgery, Australian & New Zealand Journal of Surgery,1937, 7: 134162. Kenny, Sir Patrick, ed., The Founders of the Royal Australasian College of Surgeons (Melbourne: RACS, 1984). King, K F, The Natural History of Orthopaedic Enthusiasms, Australia and New Zealand Journal of Surgery, 1993, 63:42934. Kirk, Dudley, Demographic transition theory, Populations Studies, 1996, 50: 361387.

120

Download free from www.thehistoryofsurgery.com

Kirkup, John, The Evolution o f Surgical Instruments, An Illustrated History from Ancient Times to the Twentieth Century (Novato: History of Science.com, 2006). Knafl, Kathleen and Gary Burkett, Professional socialization in a surgical specialty: acquiring medical judgment, Social Science and Medicine, 1975, 9: 397404. Knight, David, Tyrannies of Distance, in R. W. Home and Sally Gregory Kohlstedt, eds, International Science and National Scientific Identity, Australia Between Britain and America (Dordrecht: Kluwer Academic Publishers, 1991). Koempel, Jeffrey A, On the origin of tonsillectomy and the dissection method, Laryngoscope, 2002, 112:15831586. Koempel, J A, C A Solares, P J Koltai, The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleep-disordered breathing in children, Journal of Laryngology & Otology, 2006:18. Kohler, R E, Drosophila and evolutionary genetics: the moral economy of scientific practice, History of Science, 1991, 29:33575. Kuhn, Thomas S, The Structure of Scientific Revolutions (Chicago: University of Chicago Press, 1962). Kwitko, Marvin L and Charles D Kelman, eds, The History of Modern Cataract Surgery (The Hague: Kugler Publications, 1998). Laidley, J W S, A Survey of Prostatic Surgery Today, Australian & New Zealand Journal of Surgery, 1936, 5: 5463. Lane, Joan, The role of apprenticeship in eighteenth-century medical education in England, in W. F. Bynum and Roy Porter, eds, William Hunter and the Eighteenth-Century Medical World (Cambridge: Cambridge University Press, 1985). Latour, Bruno, (translated Alan Sheridan and John Law),The Pasteurization of France (Cambridge, Mass. 1988). Latour, Bruno and Steve Woolgar, Laboratory Life: the Construction of Scientific Facts (Princeton: Princeton University Press, 1986). Lawrence, Christopher, Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 18501914, Journal of Contemporary History, 1985, 20: 503520. Democratic, divine and heroic: the history and historiography of surgery, in idem, ed., Medical Theory, Surgical Practice, Studies in the History of Surgery (London: Routledge, 1992). Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain, in Christopher Lawrence and George Weisz, eds, Greater than the Parts: Holism in Biomedicine, 19201950 (Oxford: Oxford University Press, 1998). A tale of two sciences: bedside and bench in twentieth-century Britain, Medial History, 1999, 43:421449. Lawrence, Christopher and Richard Dixey, Practising on principle: Joseph Lister and the germ theories of disease, in Medical Theory, Surgical Practice. Studies in the History of Surgery (London: Routledge, 1992). Lawrence, Christopher and George Weisz, eds, Greater than the Parts: Holism in Biomedicine, 19201950 (Oxford: Oxford University Press, 1998). Lawrence, Susan C, Medical Education, in W. F. Bynum and Roy Porter, eds, Companion Encyclopedia of the History of Medicine (London: Routledge, 1993). Anatomy and Address: Creating Medical Gentlemen in Eighteenth-Century London, in Vivian Nutton and Roy Porter, eds,The History of Medical Education in Britain (Amsterdam: Rodopi, 1995).

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

121

Download free from www.thehistoryofsurgery.com

Charitable Knowledge: Hospital pupils and practitioners in eighteenthcentury London (Cambridge: Cambridge University Press, 1996). Lawrie, Surgeon Major E, Hyderabad Chloroform Commission and Professor Woods Address on Anaesthesia at Berlin, Lancet, 1890, 136: 11435. Lawson, Peter S, Origins of the Urological Society of Australasia, Australian and New Zealand Journal of Surgery, 1990, 60: 385391. Leape, L L, T A Brennan, N M Laird, et al. The nature of adverse events in hospitalized patients: Results from the Harvard Medical Practice Study II, New England J. Med, 1991, 324:377384. Leavitt, Judith Walzer, Brought to Bed: Childbearing in America, 1750 1950 (New York: Oxford University Press, 1986). Grand, Julian Le, From Knight to Knave? Public Policy and Market Incentives, in P. Taylor-Gooby, ed., Risk, Trust and Welfare (Basingstoke: Macmillan Press, 2000), pp. 2130. Lewis, Milton, Doctors, midwives, puerperal infection and the problem of maternal mortality in late nineteenth and early twentieth century Sydney, in Harold Attwood, Frank Forster & Bryan Gandevia, eds, Occasional Papers on medical History Australia (Melbourne: Medical History Society, 1984), pp. 85107. Lindon, Leonard C, The cerebro-spinal fluid in relation to neuro-surgery, Australian & New Zealand Journal of Surgery, 1937, 7: 2039. Long, W J, The Surgical Treatment of Appendicitis, Intercolonial Medical Journal of Australia, 1898, 3:60911. Longo, Lawrence D, The rise and fall of Batteys operation, Bulletin of the History of Medicine, 1979, 53: 244267. Loudon, Irvine, The concept of the family doctor, Bulletin of the History of Medicine, 1984, 58:347362. Medical Care and the General Practitioner 17501850 (Oxford: Clarendon Press, 1986). Death in Childbirth, An International Study of Maternal Care and Maternal Mortality 18001950 (Oxford: Clarendon Press, 1992). Doctors and their transport, 17501914, Medical History, 2001, 45: 185206. Love, Wilton, ed., Intercolonial Medical Congress of Australasia, Transactions of the fifth session, September 1899 (Brisbane, 1901). Ludmerer, Kenneth M, Time to Heal, American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999). McCalman, Janet, Journeyings, The Biography of a Middle-Class Generation 19201990 (Melbourne: Melbourne University Press, 1993). The power of care: the Womens Hospital 18841914, Nursing Inquiry, 1998, 5:20411. Sex and Suffering, Womens Health and a Womens Hospital (Melbourne: Melbourne University Press, 1999). Writing the Womenshospital history with medical records, Health & History, 1999, 1:10111 & 1:1328; McCalman, Janet and Ruth Morley, Mothers health and babies weights: the biology of poverty at the Melbourne Lying-in Hospital, Social History of Medicine, 2003, 16: 3956. McDonagh, John M, Notes on a case of amputation of hand for recurrent epithelioma on dorsal aspect, Aus Med Gaz, 1901, 20:68. McKeown, Thomas, The Role of Medicine: Dream, Mirage or Nemesis? (London: Nuffield Provincial Hospitals Trust, 1976).

122

Download free from www.thehistoryofsurgery.com

McLorinan, Margaret, Observations on some principles governing modern midwifery practice, Medical Journal of Australia, 1921, I: 2835. MacDonald, Helen, Human Remains, Episodes in Human Dissection (Melbourne: Melbourne University Press, 2005). Macleod, Roy, On Visiting the Moving Metropolis: reflections on the Architecture of Imperial Science, in Nathan Reingold and Marc Rothenberg, eds, Scientific Colonialism, A Cross-cultural Comparison (Washington, D. C.: Smithsonian Institution Press, 1987). Marks, Harry, The Progress of Experiment: Science and Therapeutic Reform in the United States (Cambridge: Cambridge University Press, 1997). Martyr, Philippa, Paradise of Quacks, An Alternative History of Medicine in Australia (Paddington NSW: McLeay Press, 2002). Masel, Pamela, Government Funded Hospitals and the Brisbane Community 18481923, (unpublished Honours thesis, University of Queensland, 1976). Mauss, Marcel, The Gift, The form and reason for exchange in archaic societies (New York: W W Norton, 1990 [1950]). Meldrum, M L, A Brief History of the Randomized Controlled Trial: from oranges and lemons to the gold standard, Hematology/Oncology Clinics of North America, 2000, 14:74560. Miller, Douglas, Sir Alexander MacCormick: Man and surgeon, Australia & New Zealand Journal of Surgery, 1969, 38:189195. The History of the Royal Australasian College of Surgeons from 1935 to 1960, Australian and New Zealand Journal of Surgery 41 (1972): 302311. A Surgeons Story (Sydney: John Ferguson, 1985). Miller, Joseph M, William Halsted and the use of the surgical rubber glove, Surgery, 1982, 92: 541543. Mills, S J C, D. J. Holland, and A. E. Hardy, Operative field contamination by the sweating surgeon, Australian and New Zealand Journal of Surgery, 2000, 70: 83739. Mirilas, P & J E Skandalakis, Not just an appendix: Sir Frederick Treves, Archives of Diseases of Childhood, 2003, 88: 549553. Montgomery, Mark R and Barney Cohen, eds., From Death to Birth, Mortality Decline and Reproductive Change (Washington DC: National Academy Press, 1998). Moore, Clive, Kanaka; A History of Melanesian Mackay (Boroko: Institute of Papua New Guinea Studies, 1985). Moore, W, Thiersch-grafting, Intercolonial Medical Journal, 1899, 4:435. Morantz-Sanchez, Regina, Conduct Unbecoming a Woman : Medicine on Trial in Turn-of-the-century Brooklyn (New York: Oxford University Press, 1999). Negotiating power at the bedside: historical perspectives on nineteenthcentury patients and their gynaecologists, Feminist Studies, 2000, 26:287309. Morgan, Graeme, A synopsis of radiation oncology in Australia, with particular reference to New South Wales, Australian & New Zealand Journal of Surgery, 1998, 68:225235. Morrice, Andrew, The Medical Pundits: Doctors and Indirect Advertising in the Lay Press, 19221927, Medical History, 1994, 38:25580. Honour and Interests: Medical Ethics and the British Medical Association, in Andreas-Holger Maehle and Johanna Geyer-Kordesch, eds, Historical and Philosophical Perspective on Biomedical Ethics (Aldershot: Ashgate, 2002). Moscucci, Ornella, The Science of Woman, Gynaecology and Gender in England 18001929 (Cambridge: Cambridge University Press, 1990). The ineffable freemasonry of sex: feminist surgeons and

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

123

Download free from www.thehistoryofsurgery.com

the establishment of radiotherapy in early twentieth-century Britain, Bulletin of the History of Medicine, 2007, 81: 139163. Moynihan, Sir Berkeley G A, The Ritual of a Surgical Operation, British Journal of Surgery, 1920, 8: 2735. Murphy, Leonard, The History of Urology (Springfield, Illinois: Charles C. Thomas, 1972). Harry Harris and His Contribution to Suprapubic Prostatectomy, Aust. N. Z. J. Surg., 1984, 54: 57988. Naylor, C D, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 19111966 (Montreal: McGill-Queens University Press, 1986). Naylor, G E, A case of appendicitis and a lesson, Australasian Medical Gazette, 1901, 20: 3267. Nelson, Sioban, Say Little, Do Much; Nurses, Nuns and Hospitals in the Nineteenth Century (Philadelphia: University of Pennsylvania Press, 2001). Newland, Sir Henry, The Archibald Watson Memorial Lecture, Medical Journal of Australia, 1947, II, 381387. Nicks, Rowan, The Dance of Life. The Life and Times of an Antipodean Surgeon (Melbourne: Royal Australasian College of Surgeons, 1996). Nutton, Vivian and Roy Porter, eds, The History of Medical Education in Britain (Amsterdam: Rodopi, 1995). OConnell, Dan, The outback hospitals of pre-Federation Queensland, in John Pearn, ed., Health, History and Horizons (Brisbane: Amphion Press, 1992), pp 6586. Olch, Peter D, Evarts A. Graham, The American College of Surgeons, and the American Board of Surgery, Journal of the History of Medicine & Allied Sciences, 1972, 27: 247261. Opdycke, Sandra, No One Was Turned Away; The Role of Public Hospitals in New York City since 1900 (New York: Oxford University Press, 1999). Osborn, Gladstone R and Noel Roydhouse, The Tonsillitis Habit (Christchurch NZ: W. P. Roydhouse, 1976). Page, Sir Earle, What Price Medical Care? (Philadelphia: J. B. Lippincott Company, 1960). Pang, Alex Soojung-Kim, The Social Event of the Season, Solar Eclipse Expeditions and Victorian Culture, Isis, 1993, 84: 252277. Papper, Emanuel M, The influence of romantic literature on the medical understanding of pain and suffering the stimulus to the discovery of anesthesia, Perspectives in Biology and Medicine, 1992, 35: 401; Romance, Poetry, and Surgical Sleep, Literature Influences Medicine (Westport, Connecticut: Greenwood Press, 1995). Parker, Neville and John Pearn, eds, Ernest Sandford Jackson, the Life and Times of Pioneers Australian Surgeon (Brisbane: The Australian Medical Association, Queensland Branch, 1987). Parry, Noel and Jose, The Rise of the Medical Profession, a Study of Collective Social Mobility (London: Croom Helm, 1976). Paterson, Robert, Carl Zoellera pioneer medical and veterinary agent, in Pearn, ed., Health, History and Horizons, pp. 263276. Patrick, Ross, A History of Health & Medicine in Queensland 18241960 (Brisbane: University of Queensland Press, 1987), pp. 97103. Pearn, John, ed., Health, History & Horizons (Brisbane: Amphion Press, 1992). Outback Medicine, Some Vignettes of Pioneering Medicine (Brisbane: Amphion Press, 1994); Pearn, John and Peggy Carter, eds, Bridgeheads of North-

124

Download free from www.thehistoryofsurgery.com

ern Health (Brisbane: Amphion Press, 1996). Pearn, John & Mervyn Cobcroft, eds, Fevers & Frontiers (Brisbane: Amphion Press, 1990). Pelling, Margaret, The meaning of contagion: reproduction, medicine and metaphor, in Alison Bashford and Claire Hooker, eds, Contagion, Historical and Cultural Studies (London: Routledge, 2001). Pelis, Kim, Blood standards and failed fluids: clinic lab, and transfusion solutions in London, 18681916, History of Science, 2001, 39:185211. Pennington, T H, Listerism, its decline and its persistence: the introduction of aseptic surgical techniques in three British teaching hospitals, 189099, Medical History, 1995, 39:3560. Pensabene, T S, The Rise of the Medical Practitioner in Victoria (Canberra: Australian National University, 1980). Percival, Thomas, Medical Ethics; or A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons (Manchester: J. Johnson, 1803), reprinted with an introduction by Edmund D. Pellegrino (New York: Classics of Surgery Library, 1997). Pernick, Martin S, A Calculus of Suffering: Pain Professionalism and Anesthesia in Nineteenth Century America (New York: Columbia University Press, 1985). Peterson, M Jeanne, The Medical Profession in Mid-Victorian London (Berkeley: University of California Press, 1978). Gentlemen and medical men: the problem of professional recruitment, Bulletin of the History of Medicine, 1984, 58: 457473. Phillips, Gilbert, A new method of head-fixation for operations in the sitting position, Australian & New Zealand Journal of Surgery,1937, 7:6769. Pickstone, John V, ed., Medical Innovations in Historical Perspective (Basingstoke: Macmillan,1992); Polanyi, Karl, The Great Transformation (Boston: Beacon press, 1957). Polanyi, Michael, Personal Knowledge (London: Routledge & Kegan Paul, 1958), p. 53. The Tacit Dimension (New York: Anchor Books, 1967). Poon, Christopher, David J. Morgan, Franklin Pond, John Kane, and Bruce R. Tulloh, Studies of the surgical scrub, Australian and New Zealand Journal of Surgery, 1998, 68: 6567. Porter, Dorothy and Roy Porter, eds, Patients Progress; Doctors and Doctoring in Eighteenth-century England (Stanford: Stanford University Press, 1989). Porter, Roy, Patients and Practitioners: Lay Perceptions of Medicine in Pre-industrial Society (Cambridge: Cambridge University Press, 1985). William Hunter: a surgeon and a gentleman, in W. F. Bynum and Roy Porter, eds, William Hunter and the Eighteenth-Century Medical World (Cambridge; Cambridge University Press, 1985). The Greatest Benefit to Mankind, a Medical History of Humanity from Antiquity to the Present (London: Fontana Press, 1999). Powderly, Kathleen E, Patient Consent and Negotiation in the Brooklyn Gynecological Practice of Alexander J. C. Skene: 18631900, Journal of Medicine and Philosophy, 2000, 25:1227. Power, Sir DArcy, The Cultured Surgeon, Australian and New Zealand Journal of Surgery, 1937, 6: 243247. Powles, John, Keeping the doctor away, in Verity Burgmann & Jenny Lee, eds, Making a Life, A Peoples History of Australia since 1788 (Melbourne: McPhee Gribble/Penguin, 1988). Randall, Adrian and Andrew Charlesworth, eds, Moral Economy and Popular Protest, Crowds, Conflict and Authority (Basingstoke: Macmillan Press Ltd, 2000). Randers-Pehrson, Justine, The Surgeons Glove (Springfield, Illinois: Charles C Thomas, 1960).

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

125

Download free from www.thehistoryofsurgery.com

Rasmussen, N, The moral economy of the drug company-medical scientist collaboration in interwar America, Social Studies of Science, 2004, 34:16185. Ravitch, Mark M, A Century of Surgery, The History of the American Surgical Association 18801980 (Philadelphia: J. B. Lippincott Company, 1981). Rawlings, Barbara, Coming clean: the symbolic use of clinical hygiene in a hospital sterilising unit, Sociology of Health and Illness, 1989, 11: 279293. Reiger, Kerreen, The Disenchantment of the Home. Modernizing the Australian Family 18801940 (Melbourne: Oxford University Press, 1985). Reiser, Joel S, The Technologies of Time Measurement: Implications at the Bedside and the Bench, Annals of Internal Medicine, 2000, 132: 3136. Reverby, Susan M, Ordered to Care, The dilemma of American nursing, 18501945 (Cambridge: Cambridge University Press, 1987). Richards, David, Queenslands Medical Men 18241869, in John Pearn, ed., Health, History & Horizons (Brisbane: Amphion Press, 1992), pp.191214. To Minister to the sick, an historic socio-profile of the medical profession in northern Australia, in John Pearn, ed., Outback Medicine (Brisbane: Amphion Press, 1994) pp. 2342. Richards, Stewart, Anaesthetics, ethics and aesthetics: vivisection in the late nineteenthcentury British laboratory, in Cunningham and Wear, eds, Laboratory Revolution, pp. 142169. Rinsema, Thijs J, One hundred years of Aspirin, Medical History, 1999, 43: 502507. Risse, Guenter B, Glimpses of a hidden burden: Hydatid disease in eighteenth-century Scotland, Bulletin of the History of Medicine and Allied Sciences, 2005, 79:534543. Mending Bodies, Saving Souls; A History of Hospitals (New York: Oxford University Press, 1999). Risse, Guenter B and John Harley Warner, Reconstructing Clinical Activities: Patient Records in Medical History, Social History of Medicine, 1992, 5:183205. Ritchie, Robert H, Some cases of hydatid disease, Intercolonial Medical Journal of Australasia, 1898, 3:604608. Remarks on an epidemic of diphtheria, with special reference to antitoxin treatment, Intercolonial Medical Journal, 1899, 4: 34850. Rodman, J Stewart, History of the American Board of Surgery 1937 1952 (Philadelphia: J. B. Lippincott Company, 1956). Romano, Terrie M, Gentlemanly versus Scientific Ideals: John Burdon Sanderson, Medical Education, and the Failure of the Oxford School of Physiology, Bulletin of the History of Medicine, 1997, 71: 224248. Rosen, George, The Specialization of Medicine with Particular Reference to Ophthalmology (New York: Amo Press, 1972). Rosenberg, Charles, The Care of Strangers, The Rise of Americas Hospital System (Baltimore: Johns Hopkins University Press, 1987). Ross, J E and S. M. Tomkins, The British reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1997, 52: 398423. Rowlands, G Hamilton, A case of appendicitis complicated by empyemaoperationrecovery, Australasian Medical Gazette, 1901, 20: 3256. Russell, K F, The Melbourne Medical School 18621962 (Melbourne: Melbourne University Press, 1977). Russell, R Hamilton, The etiology and treatment of inguinal hernia in the young, The Lancet, 1899, 154: 13531358.

126

Download free from www.thehistoryofsurgery.com

Papers & Addresses in Surgery, selected and revised (Melbourne: Allan Grant, 1923). The Royal College of Surgeons of England, Journal of the College of Surgeons of Australasia, 1928, 1: 49. Rutkow, Ira M, American Surgery, An Illustrated History (Philadelphia: Lippincott-Raven, 1998), Ryan, Edward, Early medical practice in north-western Victoria, in Department of Medical History, University of Melbourne, ed., Papers Presented at a Seminar on the History of Medicine, 1315 April 1966, (Sydney: Australasian Medical Publishing Co., 1968), pp. 6477. Sadler, Judy, Ideologies of Art and Science in Medicine: The transition from Medical Care to the Application of Technique in the British Medical Profession, in Wolfgang Krohn, Edwin T. Layton Jr, and Peter Weingart, eds, The Dynamics of Science and Technology (Dordrecht: D. Reidel Publishing Company, 1978). Sandelowski, M, Thermometers and Telephones, American Journal of Nursing, 2000, 100: 8286. Sanders-Goebel, Pamela, Crisis and controversy: historical patterns in breast cancer surgery, Canadian Bulletin of Medical History, 1991, 8:7790. Saunders, Kay, The Pacific Islander hospitals in colonial Queensland: the failure of liberal principles, Journal of Pacific History, 1976, 11:2850. Schlich, Thomas, Changing disease identities: cretinism, politics and surgery (18441892), Medical History, 1994, 38: 421443. Surgery, Science and Industry, a Revolution in Fracture Care, 1950s1990s (Palgrave Macmillan, Basingstoke, 2002). The emergence of modern surgery, in Deborah Brunton, ed., Medicine transformed, Health, Disease and Society in Europe 18001930 (Manchester: Manchester University Press/Open University, 2004). Trauma surgery and traffic policy in Germany in the 1930s: A case study in the co-evolution of modern surgery and society, Bulletin of the History of Medicine, 2006, 80: 7394. Surgery, Science and Modernity: operating rooms and laboratories as spaces of control, History of Science, 2007, 45: 231256. Schlink, H H, Royal Prince Alfred Hospital: its history and surgical development, Australian & New Zealand Journal of Surgery, 1933, 3: 115129. Schneider, William H, Blood transfusion in Peace and War, 1900 1918, Social History of Medicine, 1997, 10:105126. Blood Transfusion Between the Wars, Journal of the History of Medicine & Allied Sciences, 2003, 58:105126. Schofield, R, D. Reher, and A Bideau, eds., The Decline of Mortality in Europe (Oxford: Clarendon Press, 1991). Schuster, David G, Personalizing Illness and Modernity: S. Weir Mitchell, Literary Women and Neurasthenia, 18701914, Bulletin of the History of Medicine, 2005, 79:695722. Scott, Robert, A review of hydatid disease in Australasia during the decennial period, 18881897, Transactions of the Fifth Session of the Intercolonial Medical Congress of Australasia, Brisbane, Queensland, September 1899 (Brisbane: Government Printer, 1901), pp. 156182. Selby, Wendy, Motherhood in Labors Queensland, 19151957, (Unpublished PhD thesis, 1992, Griffith University). Making dowomens bush remedies, in J. Pearn, ed.,Outback Medicine (Amphion Press, Brisbane, 1994), pp. 275286. Shapin, Stephen, A Social History of Truth, Civility and Science in Seventeenth-

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

127

Download free from www.thehistoryofsurgery.com

century England (Chicago: University of Chicago Press, 1994). Shapin, S and S Schaffer, Leviathan and the Air-Pump, Hobbes, Boyle and the Experimental Life (Princeton: Princeton University Press, 1985). Sheehan, Mary, with Sonia Jennings, A professions Pathway; Nursing at St Vincents Since 1893 (Melbourne: Arcadia, 2005). Shorter, Edward, The History of the Doctor-patient Relationship, in W. F. Bynum and R. Porter, eds, Companion Encyclopedia of the History of Medicine (London: Routledge, 1993) 2: 783800. Shortt, S E D, Physicians, science, and status: issues in the professionalization of AngloAmerican medicine in the nineteenth century, Medical History, 1983, 27: 5168. Simpson, Donald, The Adelaide Medical School 18851914, A study of Anglo-Australian Synergies in Medical Education, (unpublished MD, University of Adelaide, 2000). Skirving, R Scot, The Story of the Royal College of Surgeons of Edinburgh, Journal of the College of Surgeons of Australasia, 1928, 1: 1020. Smith, Anne and B. J. Dalton, Doctor on the Landsborough : the memoirs of Joseph Arratta (Townsville: James Cook University, 1997). Smith, Colin, The Shaping of the RACS 19201960, in David E. Theile, P. H. Carter & C. V. Smith, eds, Royal Australasian College of Surgeons, Handbook (Melbourne: RACS, 1995). Smith, Dale C, Appendicitis, appendectomy, and the surgeon, Bulletin of the History of Medicine, 1996, 70: 414441. Smith, F B, The Peoples Health 18301910 (Canberra: Australian National University Press, 1979). Smith, Julian Ormond, The History of the Royal Australasian College of Surgeons from 1920 to 1935 (Melbourne: RACS, 1970). Smith, Mary E, The counting of sponges in abdominal surgery, American Journal of Nursing, 1901, 2:200202. Smith, Philippa Mein, Mothers, babies and the mothers and babies movement: Australia through depression and war, Social History of Medicine, 1993, 7:5183. Mothers and King Baby, Infant Survival and Welfare in an Imperial World: Australia 18801950 (Basingstoke: Macmillan, 1997). Springall, R G, Cholecystectomy: ironmasters and eggheads, Journal of the Royal Society of Medicine, 1988, 81:56063. Stanley, Peter, For Fear of Pain, British Surgery 17901850 (Amsterdam: Clio Medica 70, 2003). Stanton, J, ed., Innovations in Health and Medicine, Diffusion and Resistance in the Twentieth Century (London: Routledge, 2002). Stevens, Rosemary, Medical Practice in Modern England and the Impact of Specialization and State Medicine (New Haven: Yale University Press, 1966). American Medicine and the Public Interest (New Haven: Yale University Press, 1971). Stirling, R A, Surgical Operations at the Melbourne Hospital during the six months from April to October 1897, Intercolonial Medical Journal of Australia, 1898, 3:1728. Clinical Lecture, Lecture III, the Treatment of Acute Appendicitis, Intercolonial Medical Journal of Australia, 1898, 3:43747. A years surgical operations, Intercolonial Medical Journal 1899, 8199; 101165. Stowe, Steven M, Seeing Themselves at Work: Physicians and the Case Narrative in the Mid19th-Century American South, in Judith Walzer Leavitt and Ronald L. Numbers, eds, Sickness and Health in America, (Madison: University of Wisconsin Pres, 1978), 161186. Strachan, Glenda, Labour of Love; The History of the Nurses Associa-

128

Download free from www.thehistoryofsurgery.com

tion in Queensland (St Leonards: Allen and Unwin, 1996). Styrap, Jukes de, A Code of Medical Ethics with general and special rules for the guidance of the faculty and the public in the complex relations of professional life (London: H. K. Lewis, 1890) 3rd edition, pp. 328331; this is bound with: The Young Practitioner: with practical hints and instructive suggestions as subsidiary aids for his guidance on entering into private practice. Summers, Anne, They Crossed the River. The Founding of the Mater Misericordiae Hospital, Brisbane, by the Sisters of Mercy. Swain, Shurlee, The Victorian Charity Network in the 1890s (PhD, University of Melbourne, 1976). Syme, Sir George A, The Aims and Objects of the College of Surgeons of Australasia, Medical Journal of Australia, 1928, I: 488491. Szreter, Simon, The importance of social intervention in Britains mortality decline c. 1850 1914: a re-interpretation of the role of public health, Social History of Medicine, 1988, 1: 137. Tait, Lawson, An address on the surgical aspect of impacted labour, BMJ, 1890, i:657661. Address in Surgery, Lancet, 1890, 2204. Taylor, W F, The position of the medical profession, with special relation to the State of Queensland, Australasian Medical Gazette, 1901, 20: 50714. Temkin, Owsei, The Role of Surgery in the Rise of Modern Medical Thought, Bulletin of the History of Medicine, 1951, 25: 21850. Theriot, Nancy M, Womens Voices in Nineteenth-Century Medical Discourse: A Step Towards Deconstructing Science, Signs, 1993, 19:131. Negotiating illness: doctors, patients, and families in the nineteenth century, Journal of the History of the Behavioural Sciences, 2001, 37: 349368. Thompson, E P, The moral economy of the English crowd in the eighteenth century, Past and Present, 1971, 50:76136. Titmuss, Richard M, The Gift Relationship (London: George Allen and Unwin, 1970). Todd, C E, Statistics of abdominal operations at Adelaide Hospital during eleven years from January 1, 1885 to December 31, 1895, Transactions of the Fourth Session of the Intercolonial Medical Congress of Australasia, Dunedin, New Zealand, February 1896 (Dunedin: Otago Daily Times, 1897), pp 173188. Tomes, Nancy, The Gospel of Germs: Men, Women and the Microbe in American Life (Cambridge Mass.: Harvard University Press, 1998). Tomes, Nancy and John Harley Warner, Introduction to special issue on rethinking the reception of the germ theory of disease: comparative perspectives, Journal of the History of Medicine, 1997, 52: 716. Treves, Frederick, ed., A Manual of Surgery in treatises by various authors in three volumes (London: Cassell & Company, 1888) 3 vols. Trhler, Ulrich, To operate or not to operate? Scientific and extraneous factors in therapeutical controversies within the Swiss Society of Surgery 19131988, Clio Medica, 1991, 22: 89113. Surgery (modern), in W. F. Bynum and Roy Porter, eds, Companion Encyclopedia of the History of Medicine, volume 2 (London: Routledge, 1997) pp. 9841007. Turnbull, David, Masons, Tricksters and Cartographers, Comparative Studies in the Sociology of Scientific and Indigenous Knowledge (Harwood Academic Publishers, 2000). Turner, Victor W, The Ritual Process (London: Routledge & Kegan Paul, 1969). Tyquin, Michael, A Place on the Hill, The History of St Vincents Private Hospitals in

Sally Wilde, The History of Surgery

Sally Wilde, The History of Surgery

129

Download free from www.thehistoryofsurgery.com

Melbourne 190693 (Melbourne: Hargreen Publishing Company, 1997). Tyrer, J H, History of the Brisbane Hospital: A Pilgrims Progress (Brisbane: Boolarong Publications, 1993). Helvoort, Ton Van, Scalpel or rays? Radiotherapy and the struggle for the cancer patient in pre-Second World War Germany, Medical History, 2001, 45: 3360. Vance, W B, A Report of Three Months Abdominal Surgery Performed at the Alfred Hospital, Melbourne by Henry M. OHara, F.R.C.S.I., Senior Surgeon to the Hospital, Intercolonial Medical Journal of Australia, 1898, 3:8694. Vellar, Ivo D, Thomas peel Dunhill: pioneer thyroid surgeon, (unpublished MS thesis, University of Melbourne, 1997). Thomas Peel Dunhill: pioneer thyroid surgeon, Australia & New Zealand Journal of Surgery, 1999, 69:375387. Hugh Berchmans Devine: Surgical Visionary and Great Austalian, Australian & New Zealand Journal of Surgery, 2000, 70: 801812. The Doers, History of Surgery at St Vincents Hospital Melbourne 1890s1950s (Melbourne: Publishing Solutions, 2002). Surgery and surgeons at St Vincents Hospital Melbourne 1950s 2000 (Melbourne: Publishing Solutions, 2004); Vigarello, Georges, Concepts of Cleanliness: Changing Attitudes in France since the Middle Ages, trans Jean Birrell (Cambridge: Cambridge University Press, 1988). Wailoo, Keith, Drawing Blood, Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1999). Walker-Smith, John, Sir George Newman, infant diarrhoeal mortality and the paradox of urbanism, Medical History, 1998, 42: 347361. Wangensteen, Owen H, Surgery and Surgical Travel Groups, Surgery Gynecology & Obstetrics, 1978, 147: 246254. Ward, Patricia Spain, The American reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1981, 36:4462. Warner, John Harley, The Therapeutic Perspective: Medical Practice, Knowledge and Identity in America 18201885 (Cambridge, Mass.: Harvard University Press, 1986). The history of science and the sciences of medicine, Osiris 1995, 10: 164193; The Uses of Patient Records by Historianspatterns, possibilities and perplexities, Health & History, 1999, 1:10111. Webb, Sidney & Beatrice, The State and the Doctor (London: Longmans Green and Co. 1910). Warren, M E, ed., Democracy and Trust (Cambridge: Cambridge University Press, 1999). Warwick, Andrew, X-rays as Evidence in German Orthopaedic Surgery, 18951900, Isis, 2005, 96, 124. Weisz, George, Divide and Conquer, a Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006). White, K N, Negotiating Science and Liberalism: Medicine in Nineteenth-Century South Australia, Medical History, 1999, 43:173191. Wilde, Sally, Forests Old, Pastures New, A History of Warragul (Shire of Warragul, 1988). The History of Prahran Volume II 19251990 (Melbourne: MUP, 1993). Joined Across the Water, A History of the Urological Society of Australasia (Melbourne: Hyland House, 1999). Practising Surgery, A history of surgical training in Australia 19271974, (unpublished PhD thesis, University of Melbourne, 2003).

130

Download free from www.thehistoryofsurgery.com

See One, Do One, Modify One, Prostate Surgery in the 1930s, Medical History, 2004, 48:351366. Surgical Theatre, Gifted Performance: The moral economy of surgical training, in Christy Collis and Maggie Nolan, eds, Benevolence, Journal of Australian Studies 85 (Perth: API Network, Australia Research Institute, 2005) 2736; 1948. The elephants in the doctor-patient relationship, Health & History, 2007, 9: 126. Truth, trust and confidence in surgery, 18901910: patient autonomy, communication & consent, Bulletin of the History of Medicine, 2009, 83(2): 302330. Wilde, Sally and Geoffrey Hirst, Your Prostate, Your Choices (Sydney: Bantam, 1999). Learning from mistakes: early twentieth century surgical practice, Journal of the History of Medicine & Allied Sciences, 2009, 64(1): 3877. Williams, Lesley, Feminine frontiers in John Pearn and Mervyn Cobcroft, eds, Fevers and Frontiers (Brisbane: Amphion Press, 1990), pp135158. No Easy Path, The life and times of Lilian Violet Cooper MD, FRACS (18611947) Australias first woman surgeon, (Brisbane: Amphion Press, 1991). Willis, Evan, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989). Woods, R I, P A Watterson and J H Woodward, The causes of rapid infant mortality decline in England and Wales 18611921 Part I, Population Studies, 1988, 42: 342366. The causes of rapid infant mortality decline in England and Wales, 18611921 Part II, Population Studies, 1989, 43: 113132. Woolcock, Helen R, M. John Thearle and Kay Saunders, My Beloved Chloroform. Attitudes to Childbearing in Colonial Queensland, Social History of Medicine, 1997, 437457. Worboys, Michael, Spreading Germs, Disease Theories and Medical Practice in Britain, 18651900 (Cambridge: Cambridge University Press, 2000). Wright, R Douglas, Therapy by radium and X rays, Australian & New Zealand Journal of Surgery, 1937, 7: 114126. Young, John Atherton, Ann Jervie Sefton, and Nina Webb, eds, Centenary Book of the University of Sydney Faculty of Medicine (Sydney: Sydney University Press, 1984). Yule, Peter, The Royal Childrens Hospital: a history of faith, science and love (Rushcutters Bay: Halstead Press, 1999). Zuck, D, Mr Troutbeck as the Surgeons Friend: The Coroner and the DoctorsAn Edwardian Comedy, Medical History, 1995, 39:259287.

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Notes
Notes for Introduction

Many surgeons have written detailed and informative works on the history of their specialties, including: Ira M. Rutkow, American Surgery, An Illustrated History (Philadelphia: LippincottRaven, 1998); Marvin L. Kwitko & Charles D. Kelman, eds, The History of Modern Cataract Surgery (The Hague: Kugler Publications, 1998); Steven Friedman, A History of Vascular Surgery (Malden: Blackwell, 2005); Leonard Murphy, The History of Urology (Springfield, Illinois: Charles C. Thomas, 1972); John Kirkup, The Evolution of Surgical Instruments, An Illustrated History from Ancient Times to the Twentieth Century (Novato: History of Science.com, 2006). George Bernard Shaw, The Doctors Dilemma, Preface on doctors, accessed through Project Gutenberg, 7.02.08: www.gutenberg.org/catalog/world/readfile?fk_files=9508&pageno=2. For a succinct and highly readable introduction to the history of medicine see: Roy Porter, The Greatest Benefit to Mankind, a Medical History of Humanity from Antiquity to the Present (London: Fontana Press, 1999); see also W. F. Bynum, Anne Hardy, Stephen Jacyna, Christopher Lawrence and Tilli Tansey, The Western Medical Tradition 1800-2000 (Cambridge: Cambridge University Press, 2006). Ludwig Fleck, Genesis and Development of a Scientific Fact, trans. Fred Bradley and Thaddeus J. Trem (Chicago: University of Chicago Press, 1979); Bruno Latour and Steve Woolgar, Laboratory Life: the Construction of Scientific Facts (Princeton: Princeton University Press, 1986); Harry Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States (Cambridge: Cambridge University Press, 1997); Carol Ballentine, Taste of raspberries, taste of death, the 1937 Elixir of Sulfanilamide incident, US Food and Drug Administration Home Page, www.fda.gov/oc/history/elixir.html, accessed 5.02.08. For a review of the literature see: Christopher Lawrence, Democratic, divine and heroic: the history and historiography of surgery, in idem, ed., Medical Theory, Surgical Practice, Studies in the History of Surgery (London: Routledge, 1992); see also Thomas Schlich, The emergence of modern surgery, in Deborah Brunton, ed., Medicine transformed, Health, Disease and Society in Europe 1800-1930 (Manchester: Manchester University Press/Open University, 2004). Archives of the Urological Society of Australasia, held in the Royal Australasian College of Surgeons Archives Melbourne: M S S Earlam and J W S Laidley, Item 78, surgical diaries 1936-7, 1938 and 1948, Earlam, 25 Nov., 1938. Thomas S. Kuhn, The Structure of Scientific Revolutions (Chicago: University of Chicago Press, 1962). Christopher Lawrence and Richard Dixey, Practising on principle: Joseph Lister and the germ theories of disease, in Medical Theory, Surgical Practice; Lindsay Granshaw, Upon this principle I have based a practice: the development and reception of antisepsis in Britain, 1867-90, in John V. Pickstone, ed., Medical Innovations in Historical Perspective (Basingstoke: Macmillan, 1992); T. H. Pennington, Listerism, its decline and its persistence: the introduction of aseptic surgical techniques in three British teaching hospitals, 1890-99, Medical History, 1995, 39:35-60; Jerry L. Gaw, A Time to Heal: The Diffusion of Listerism in Victorian Britain (Philadelphia: American Philosophical Society, 1999); Anna Greenwood, Lawson Tait and Opposition to Germ Theory: Defining

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Science in Surgical Practice, Journal of the History of Medicine, 1998, 53:99-13; Michael Worboys, Spreading Germs, Disease Theories and Medical Practice in Britain, 1865-1900 (Cambridge: Cambridge University Press, 2000), especially chapters 3 and 5; Margaret Pelling, The meaning of contagion: reproduction, medicine and metaphor, in Alison Bashford and Claire Hooker, eds, Contagion, Historical and Cultural Studies (London: Routledge, 2001); Thomas B. Hugh, The beginning of antiseptic surgery in Australia, Australia & New Zealand Journal of Surgery, 1995, 65: 887-889. 9 K. Codell Carter, Kochs postulates in relation to the work of Jacob Henle and Edwin Klebs, Medical History, 1985, 29:353-374; Andrew Cunningham, Transforming plague: the laboratory and the identity of infectious disease, in A. Cunningham and P. Williams, eds, The Laboratory Revolution in Medicine (Cambridge: Cambridge University Press, 1992), pp. 209-244.

10 Thomas McKeown, The Role of Medicine: Dream, Mirage or Nemesis? (London: Nuffield Provincial Hospitals Trust, 1976); Nancy Tomes, The Gospel of Germs: Men, Women and the Microbe in American Life (Cambridge Mass.: Harvard University Press, 1998). 11 Patricia Spain Ward, The American reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1981, 36:44-62; J. E. Ross and S. M. Tomkins, The British reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1997, 52: 398-423. 12 S. E. D. Shortt, Physicians, science, and status: issues in the professionalization of AngloAmerican medicine in the nineteenth century, Medical History, 1983, 27: 51-68; Christopher Lawrence, Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain, in Christopher Lawrence and George Weisz, eds, Greater than the Parts: Holism in Biomedicine, 1920-1950 (Oxford: Oxford University Press, 1998); see also the classic article on the importance of a gentlemanly background: Christopher Lawrence, Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850-1914, Journal of Contemporary History, 1985, 20: 503-520 and M. Jeanne Peterson, Gentlemen and medical men: the problem of professional recruitment, Bulletin of the History of Medicine, 1984, 58: 457-473.
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13

Most of the literature concerns the medical profession in the United States: Eliot Friedson, Professional Dominance: The Social Structure of Medical Care (Chicago: Aldine, 1970); Paul Starr, The Social Transformation of American Medicine (New York: Basic Nooks, 1982); John B. McKinlay, The end of the Golden Age of Doctoring, New England Research Institutes Network, 1999, 1:3.; for Australia see: Evan Willis, Medical Dominance, the Division of Labour in Australian Health Care (Sydney: Allen & Unwin, 1989); T. S. Pensabene, The Rise of the Medical Practitioner in Victoria (Canberra: Australian National University, 1980). For the rise of the professions more broadly, see: Harold Perkin, The Rise of Professional Society: England Since 1880 (New York: Routledge, 2002).

14 H. W. Armit, A Matter of Ethics (editorial) Medical Journal of Australia, [MJA], 1921, I:443. 15 For a survey of the literature see: Donald W. Light, The medical profession and organizational change: from professional dominance to countervailing power, in Chloe E. Bird, Peter Conrad and Allen M. Fremont, eds, Handbook of Medical Sociology (New Jersey: Prentice Hall, 2000), pp. 201-216. 16 Richard M. Titmuss, The Gift Relationship (London: George Allen and Unwin, 1970). Subsequent developments have, however, significantly modified the picture described by Titmuss. 17 Sally Wilde, Surgical Theatre, Gifted Performance: The moral economy of surgical training, in Christy Collis and Maggie Nolan, eds, Benevolence, Journal of Australian Studies 85 (Perth:

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API Network, Australia Research Institute, 2005) 27-36; 194-8; the classic article on moral economy is: E. P. Thompson, The moral economy of the English crowd in the eighteenth century, Past and Present, 1971, 50:76-136; for an extended discussion of the term, see: Adrian Randall and Andrew Charlesworth, eds, Moral Economy and Popular Protest, Crowds, Conflict and Authority (Basingstoke: Macmillan Press Ltd, 2000); for the use of the term in an Australian context, see: Ben Maddison, From Moral Economy to Political Economy in New South Wales, 1870-1900, Labour History, 1998, 75:81-107; Stuart Macintyre, A Colonial Liberalism: The Lost World of Three Victorian Visionaries (Melbourne: Oxford University Press, 1991), especially pp. 87-97; A. Wells, State Regulation for a Moral Economy: Peter Macarthy and the Meaning of the Harvester Judgment, The Journal of Industrial Relations, 1998, 40:371-82; for a wider view see: W. J. Booth, On the idea of moral economy, American Political Science Review, 1994, 88:653-68. The idea of moral economy is discussed at some length in Part 2 below. 18 Frank Honigsbaum, Health, Happiness, and Security, The creation of the National Health Service (London: Routledge, 1989); J. Rogers Hollingsworth, A Political Economy of Medicine: Great Britain and the United States (Baltimore: Johns Hopkins University Press, 1986); Rosemary Stevens, Medical Practice in Modern England and the Impact of Specialization and State Medicine (New Haven: Yale University Press, 1966); Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971); James A. Gillespie, The Price of Health: Australian Governments and Medical Politics 1910-1960 (Melbourne: Cambridge University Press, 1991); Sidney Sax, Medical Care in the Melting Pot (Sydney: Angus and Robertson, 1972); Sidney Sax, A Strife of Interests. Politics and Policies in Australian health services (Sydney: George Allen and Unwin, 1984). C. D. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Montreal: McGill-Queens University Press, 1986). W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994); John Harley Warner, The history of science and the sciences of medicine, Osiris 1995, 10: 164-193; Cunningham and William, eds, The Laboratory Revolution in Medicine; in the colonial context, Kevin White has argued that the importance of science in validating medicine has been oversimplified: K.N. White, Negotiating Science and Liberalism: Medicine in Nineteenth-Century South Australia, Medical History, 1999, 43:173-191; also on the importance of politics as well as science in validating knowledge see: Ian A. Burney, Bodies of Evidence, Medicine and the Politics of the English Inquest, 1830-1926 (Baltimore: Johns Hopkins University Press, 2000). Deborah Brunton, The rise of laboratory medicine, in Deborah Brunton, ed., Medicine Transformed, pp.92-118; John V. Pickstone, ed., Medical Innovations in Historical Perspective (Basingstoke: Macmillan,1992); Thijs J. Rinsema, One hundred years of Aspirin, Medical History, 1999, 43: 502-507. Martin S. Pernick, A Calculus of Suffering: Pain Professionalism and Anesthesia in Nineteenth Century America (New York: Columbia University Press, 1985); Peter Stanley has argued that surgery before anaesthesia was not necessarily either fast or crude and that the number and range of operations was rising before the introduction of anaesthesia: Peter Stanley, For Fear of Pain, British Surgery 1790-1850 (Amsterdam: Clio Medica 70, 2003); Emanuel M. Papper, The influence of romantic literature on the medical understanding of pain and suffering - the stimulus to the discovery of anesthesia, Perspectives in Biology and Medicine, 1992, 35: 401; idem, Romance, Poetry, and Surgical Sleep, Literature Influences

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Medicine (Westport, Connecticut: Greenwood Press, 1995); Ian Burney, Anaesthesia and the evaluation of surgical risk in mid-nineteenth-century Britain, in Thomas Schlich and Ulrich Trhler, eds, The Risks of Medical Innovation (London: Routledge, 2006), pp. 3852; Margaret C. Jacob and Michael J. Sauter, Why did Humphrey Davy and associates not pursue the pain-alleviating effects of nitrous oxide? Journal of the History of Medicine, 2002, 57: 161-176; for an alternative to the standard explanation for falling death rates from surgery see: David Hamilton, The nineteenth-century surgical revolution antisepsis or better nutrition?, Bulletin of the History of Medicine, 1982, 56:30-40. 22 23 Schlich, The emergence of modern surgery; Owsei Temkin, The Role of Surgery in the Rise of Modern Medical Thought, Bulletin of the History of Medicine, 1951, 25: 218-50. Nancy J. Tomes and John Harley Warner, Introduction to special issue on rethinking the reception of the germ theory of disease: comparative perspectives, Journal of the History of Medicine, 1997, 52: 7-16; see also the other articles in this special issue of the Journal of the History of Medicine; Anna Greenwood, Lawson Tait and Opposition to Germ Theory: Defining Science in Surgical Practice, Journal of the History of Medicine, 1998, 53:99-13; for the argument that surgeons learned from nurses in combating wound infection, see Alison Bashford, Purity and Pollution : Gender, Embodiment and Victorian Medicine (St Martins Press, New York, 1998); Worboys, Spreading Germs. Lawrence and Dixey, Practising on principle. Sally Wilde, Truth, Trust and Confidence in Surgery, 1890-1910: Patient autonomy, communication and consent, Bulletin of the History of Medicine, 2009, 83(2): 302-330; Morris J. Vogel and Charles E. Rosenberg, eds, The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia: University of Pennsylvania Press, 1979). Ross Patrick, A History of Health & Medicine in Queensland 1824-1960 (Brisbane: University of Queensland Press, 1987), pp. 97-103. At the turn of the century, there was considerable public anxiety about falling birth rates. For Australia see: Neville Hicks, This Sin and Scandal, Australias Population Debate 1891-1911(Canberra: Australian National University Press, 1978); pro-natalist policies from State governments were associated, among other things, with measures designed to try and reduce infant and maternal mortality: Philippa Mein Smith, Mothers and King Baby, Infant Survival and Welfare in an Imperial World: Australia 1880-1950 (Basingstoke: Macmillan, 1997); Wendy Selby, Motherhood in Labors Queensland, 1915-1957, (Unpublished PhD thesis, 1992, Griffith University); Milton Lewis, Doctors, midwives, puerperal infection and the problem of maternal mortality in late nineteenth and early twentieth century Sydney, in Harold Attwood, Frank Forster & Bryan Gandevia, eds, Occasional Papers on Medical History Australia (Melbourne: Medical History Society, 1984), pp. 85-107. Simon Szreter, The importance of social intervention in Britains mortality decline c. 1850-1914: a re-interpretation of the role of public health, Social History of Medicine, 1988, 1: 1-37; Bernard Harris, Public health, nutrition, and the decline of mortality: the McKeown thesis revisited, Social History of Medicine, 2004, 17: 379-407; the changing virulence of organisms may also have played a role: Irvine Loudon, Death in Childbirth, An International Study of Maternal Care and Maternal Mortality 1800-1950 (Oxford: Clarendon Press, 1992); for the argument that public health measures, especially the imposition of clean-

24 25

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28

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liness and order, materially improved death rates at sea, see: Robin Haines, Doctors at Sea, Emigrant Voyages to Colonial Australia (Basingstoke: Palgrave Macmillan, 2005). 29 In 1996, the journal Population Studies published a special issue giving an overview of the enormous body of literature on fertility decline up until that date, including: Dudley Kirk, Demographic transition theory, Populations Studies, 1996, 50: 361-387; D. J. van de Kaa, Anchored narratives: the story and findings of half a century of research into the determinants of fertility, Populations Studies, 1996, 50: 389-342; see also Alain Bideau, Bertrand Desjardins, and Hctor Prez Brignoli, eds., Infant and Child Mortality in the Past (Oxford: Clarendon Press, 1997); Robert Woods, The Demography of Victorian England and Wales (Cambridge: Cambridge University Press, 2000); Mark R. Montgomery and Barney Cohen, eds., From Death to Birth, Mortality Decline and Reproductive Change (Washington DC: National Academy Press, 1998); John Walker-Smith, Sir George Newman, infant diarrhoeal mortality and the paradox of urbanism, Medical History, 1998, 42: 347-361; R.I. Woods, P. A. Watterson & J. H. Woodward, The causes of rapid infant mortality decline in England and Wales 1861-1921 Part I, Population Studies, 1988, 42: 342-366. Patrick, A History of Health & Medicine in Queensland, pp. 438-441; Philippa Mein Smith, Mothers, babies and the mothers and babies movement: Australia through depression and war, Social History of Medicine, 1993, :51-83; Janet McCalman and Ruth Morley, Mothers health and babies weights: the biology of poverty at the Melbourne Lying-in Hospital, Social History of Medicine, 2003, 16: 39-56; Loudon, Death in Childbirth, pp. 463-482. Neville Hicks notes that Australian women who began their childbearing in 1911 had, on average, four children or less, compared to their grandmothers, who had at least seven. This Sin and Scandal, p. 157. Sally Wilde, The elephants in the doctor-patient relationship, Health & History, 2007, 9: 1-27. For the significance of technological assemblages see: Wiebe E. Bijker, Of Bicycles, Bakelites, and Bulbs, Toward a Theory of Sociotechnical Change (Cambridge, Mass.: The MIT Press, 1995); for technological innovation in surgery see below chapter 4. F. B. Smith, The Peoples Health 1830-1910 (Canberra: Australian National University Press, 1979), p.9. Anne Digby, Making a Medical Living: Doctors and Patients in the English Market, 1720-1911 (Cambridge: Cambridge University Press, 1994); idem, The Evolution of the British General Practitioner 1850-1948 (Oxford: Oxford University Press, 1999); Irvine Loudon, Medical Care and the General Practitioner 1750-1850 (Oxford: Clarendon Press, 1986); John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge and Identity in America 1820-1885 (Cambridge, Mass.: Harvard University Press, 1986). Much of the pioneering work on patient perspectives concerned the eighteenth century, especially in England. See: Roy Porter, ed., Patients and Practitioners; Lay Perceptions of Medicine in Pre-industrial Society (Cambridge: Cambridge University Press, 1985); Dorothy Porter and Roy Porter, eds, Patients Progress; Doctors and Doctoring in Eighteenth-century England (Stanford: Stanford University Press, 1989); Nancy M. Theriot, Negotiating illness: doctors, patients, and families in the nineteenth century, Journal of the History of the Behavioural Sciences, 2001, 37: 349-368; Regina Morantz-Sanchez, Negotiating power at the bedside: historical perspectives on nineteenth-century patients and their gynaecologists, Feminist Studies, 2000, 26:287-303 For an overview of the historiography of place, and especially colonial place, in science see: David Wade Chambers & Richard Gillespie, Locality in the History of Science; Co-

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32 33

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lonial Science, Technoscience, and Indigenous Knowledge, Osiris, 2000, 15:221-240. 37 David Wade Chambers, Does distance tyrannize science? and David Knight, Tyrannies of Distance, both in R. W. Home and Sally Gregory Kohlstedt, eds, International Science and National Scientific Identity, Australia Between Britain and America (Dordrecht: Kluwer Academic Publishers, 1991); David Wade Chambers, Locality and Science: Myths of Centre and Periphery, in A. Lafuente, A. Elena and M. L. Ortega, eds, Mundializacion de la ciencia y cultura nacional, Actas del Congreso Internacional <Ciencia, descubrimiento y mundo colonial> (Madrid: Doce Calles, 1993); Roy Macleod, On Visiting the Moving Metropolis: reflections on the Architecture of Imperial Science, in Nathan Reingold and Marc Rothenberg, eds, Scientific Colonialism, A Crosscultural Comparison (Washington, D. C.: Smithsonian Institution Press, 1987). John Pearn, ed., Outback Medicine, Some Vignettes of Pioneering Medicine (Brisbane: Amphion Press, 1994); idem, Health, History & Horizons (Brisbane: Amphion Press, 1992); John Pearn and Peggy Carter, eds, Bridgeheads of Northern Health (Brisbane: Amphion Press, 1996); John Pearn & Mervyn Cobcroft, eds, Fevers & Frontiers (Brisbane: Amphion Press, 1990); Neville Parker and John Pearn, eds, Ernest Sandford Jackson, the Life and Times of a Pioneer Australian Surgeon (Brisbane: The Australian Medical Association, Queensland Branch, 1987). Just over one in five of the 350 doctors on the roll of the Intercolonial Medical Congress of Australasia in Brisbane in 1899 had Australasian qualifications. Of the rest, 8 had qualifications from North America or continental Europe. The remaining 76% all had Irish, Scottish or English qualifications. Wilton Love, ed., Intercolonial Medical Congress of Australasia, Transactions of the fifth session, September 1899 (Brisbane, 1901), pp. 5-12. Donald Simpson, The Adelaide Medical School 1885-1914, A study of Anglo-Australian Synergies in Medical Education, (unpublished MD, University of Adelaide, 2000); Laurence M. Geary, The Scottish-Australian Connection 1850-1900, in Vivian Nutton and Roy Porter, eds, The History of Medical Education in Britain, (Amsterdam: Rodopi, 1995); Anne Crowther and Marguerite Dupree, The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century, Bulletin of the History of Medicine,1996, 70(3):387-413; K. F. Russell, The Melbourne Medical School 1862-1962 (Melbourne: Melbourne University Press, 1977); Diana Dyason, The medical profession in colonial Victoria, 1834-1901, in Roy Macleod and Milton Lewis, eds, Disease, Medicine and Empire (London: Routledge, 1988), pp 194-216; England also had a major influence on the patterns of medical care developed in North America. See, for example, Eric Christianson, Medicine in New England, in Judith Walzer Leavitt and Ronald L. Numbers, eds, Sickness and Health in America, pp. 47-71. Sarah Wilde, Practising Surgery, A history of surgical training in Australia 1927-1974, (unpublished PhD thesis, University of Melbourne, 2003).

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40

Notes for Chapter 1

41 42 43

H. H. Schlink, Royal Prince Alfred Hospital: its history and surgical development, Australian & New Zealand Journal of Surgery, 1933, 3: 115-129, p. 122. Queensland State Archives, Brisbane, Inquests, JUS files.. Throughout the text, patients and their families have been given false names, unless their sto-

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ries are already in the public domain as the result of newspaper articles or other publications. 44 45 John Oxley Collection, Queensland State Library, Bettie Clark Diary, 20 Jun 1882-19 Jan 1898, M1176/1, Box 3919 O/S. Dr J Collis Brownes Chlorodyne, a mixture of chloroform and morphine and one of the most popular proprietary brands of infant soother. Lynette Finch, Soothing Syrups and Teething Powders: Regulating Proprietary Drugs in Australia, 1860-1910, Medical History, 1999, 43:74-94. Queensland State Archives, Inquests, JUS/N 331, 1905, file 99/05. Queensland State Archives, Inquests, JUS/N 222, 1894, file 124/94. In this era, male nurses (wardsmen) were more common in outback hospitals than female nurses. Queensland State Archives, Inquests, JUS/ N 331, 1905, file 91/05. Queensland State Archives, Inquests, JUS/ N 919, 1930, file 854/30. Aspirin, one of the greatest sellers in the history of the pharmaceutical industry, was first marketed by the German company Friedrich Bayer & Co. in 1899. Although priority in its synthesis (invention? or discovery?) is disputed, this synthetic form of salicylic acid, with fewer unpleasant side effects than earlier versions, emerged from work by scientists in Bayers laboratories. Thijs J. Rinsema, One hundred years of Aspirin, Medical History, 1999, 43: 502-507; Anne Adina Andermann, Physicians, fads and pharmaceuticals: a history of aspirin, Crossroads: where medicine and humanities meet, McGill University www.medicine.mcgill.ca/mjm/issues/c02n02/aspirin.html accessed 22.2.08. Queensland State Archives, Inquests, JUS/ N 928, 1931, file 391/31. William Hastings, Diaries, 1880; 1883-4; 1884-5; 1886-8; 1889-90; 1890-92; 18947; originals, Warragul Historical Society; copies, State Library of Victoria, La Trobe collection MS8919, B445; other volumes Keith Osler, private collection. Queensland State Archives, Inquests, JUS/N 281, 1900, file 33/00. Queensland State Archives, Inquests, JUS/N 910, 1930, file 439/30. Queensland State Archives, Inquests, JUS/N 932, 1931, file 568/31. Queensland State Archives, Inquests, JUS/N 922, 1931, file 106/31. Queensland State Archives, Inquests, JUS/N 791, 1925, file 30/25. Truth, 16 October 1931, 25 October 1931 For abortions performed by doctors, see: Queensland State Archives, Inquests, JUS/N 898, 1929, file 841/29. Queensland State Archives, Inquests, JUS/N 927, 1931, file 380/31. For segregation in Queensland Hospitals see: Clive Moore, Kanaka; A History of Melanesian Mackay (Boroko: Institute of Papua New Guinea Studies, 1985), espec. pp. 235-244; Selby, Motherhood in Labors Queensland; Kay Saunders, The Pacific Islander hospitals in colonial Queensland: the failure of liberal principles, Journal of Pacific History, 1976, 11:28-50. Queensland State Archives, Inquests, JUS/N 231, 1895, file 56/95. Queensland State Archives, Inquests, JUS/N 928, 1931, file 383/31.

46 47 48 49 50 51

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54 55 56 57 58 59 60 61 62

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Queensland State Archives, Inquests, JUS/N 25, 1894, file 298/94.

Notes for Chapter 2

66 67 68 69 70 71 72 73 74

W. S. Byrne, Caesarean Section (Sanger-Leopold Operation), The Australasian Medical Gazette, 1892, 11: 147-149; see also pp. 252-3. Ibid, p. 148. J. Lockhart Gibson, Removal of adenoid growths from the naso-pharynx, Intercolonial Quarterly Journal of Medicine and Surgery, 1895-6, II: 223-231. RACS Archives Melbourne: Archibald Watson, Se 64, P1/2/5 Aug 27- Nov 11 1897 W. Cavenagh-Mainwaring, Rupture of the vaginal wall, Aus Med Gaz, 1900, 19:147-8. Alex Young Fullerton, A Case of Acute Intestinal ObstructionOperationRecovery, The Australasian Medical Gazette, April 20, 1900, XIX. Douglas Miller, A Surgeons Story (Sydney: John Ferguson, 1985), p. 67. Margaret McLorinan, Observations on some principles governing modern midwifery practice, Medical Journal of Australia, 1921, I: 283-5. Loudon, The concept of the family doctor; Digby, Making a Medical Living; idem, The Evolution of the British General Practitioner; Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750-1950 (New York: Oxford University Press, 1986); Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840-1883 (New York: Cambridge University Press, 1984); see also: Edward Shorter, The History of the Doctor-patient Relationship, in W. F. Bynum and R. Porter, eds, Companion Encyclopedia of the History of Medicine (London: Routledge, 1993) 2: 783-800; Regina Morantz-Sanchez, Negotiating power at the bedside: historical perspectives on nineteenth-century patients and their gynaecologists, Feminist Studies, 2000, 26: 287-309; Porter, Patients and Practitioners; Wilde, The Elephants; Nancy M. Theriot, Womens Voices in Nineteenth-Century Medical Discourse: A Step Towards Deconstructing Science, Signs, 1993, 19:1-31; idem, Negotiating illness: doctors, patients and families in the nineteenth century, Journal of the History of the Behavioural Sciences, 2001, 37:349-368; Kathleen E. Powderly, Patient Consent and Negotiation in the Brooklyn Gynecological Practice of Alexander J. C. Skene: 1863-1900, Journal of Medicine and Philosophy, 2000, 25:12-27; David G. Schuster, Personalizing Illness and Modernity: S. Weir Mitchell, Literary Women and Neurasthenia, 1870-1914, Bulletin of the History of Medicine, 2005, 79:695-722. Aus Med Gaz, 1890, 10: 78-9. This was a case in country New South Wales. C. H. W. Hardy, An extra-uterine foetation, Aus Med Gaz, 1900, 19: 223-5. G. A Fischer, Otitic Septic Sinus Thrombosis, Radical Operation, Ligation, and Excision of Internal Jugular VeinCure, Aus Med Gaz, 1900, 19: 186-7. Aus Med Gaz, 1891, 11: 151. See, for example, An unqualified practitioner convicted of manslaughter, BMJ, 1890, II: 423; Martyr, Paradise of Quacks; Waltraud Ernst, ed., Plural Medicine, Tradition and Modernity, 18002000 (London: Routledge, 2002). At the time, Dr Batchelor was one of the three honorary surgeons to the Dunedin Hospital. L. E. Barnett, The evolution of the Dunedin Hospital and

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75 76 77 78 79

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Medical School: a brief history, Australian & New Zealand Journal of Surgery, 1934, 3: 307-317. 80 81 Cunneen vs Cooper, NSW, 1895. Aus Med Gaz, 1890, 10: editorial, 208-210; reply from Dr. Pratt, 256-7. The lad Cunneen was awarded 400 and costs against Dr. Cooper for malpractice. The arm later healed. Thomas B. Walley, letter to the editor, Aus Med Gaz, 1900, p. 129. George Lane Mullins, The Duties and Responsibilities of Medical Practitioners in New South Wales, Aus Med Gaz, 1895, 14: 532-4. Charles MacLaurin, Radical Cure of Inguinal Hernia, with an Account of a new Operation, Aus Med Gaz, 1900, 19: 602. Dr Hyde from Clyde, New Zealand, during a discussion on appendicectomy, Intercolonial Medical Congress of Australasia, Transactions of the Fifth Session, Brisbane, September 1899 (Brisbane: Government Printer, 1901), p. 212. Ibid, p. 217. Dr Pinnock in discussion of: J. O. Closs, Hypertrophy of the prostate, Transactions of the fourth session of the Intercolonial Medical Congress of Australasia, 1896 (Dunedin: Otago Daily Times, 1896), 191-198. E. Sandford Jackson, An Address, MJA, 1926, II: 855-861, p.859. W. Moore, Thiersch-grafting, Intercolonial Medical Journal, 1899, 4: 43-5. Brisbane Courier-Mail, 15 July 1935, p. 11.

82 83 84

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91 92

Victor Hurley, An outline of a suggested policy for the College of Surgeons of Australasia for the improvement of hospitals, Journal of the College of Surgeons of Australasia, 1928, 1: 43-52. There were four intermediate hospitals at the time and they, too, were far larger than the average private hospital, with 250 beds between them: Hurley, An outline of a suggested policy for the College of Surgeons of Australasia for the improvement of hospitals. See also Victorian Year Books for hospital statistics in this period. Diana Dyason, William Gillbee and Erysipelas at the Melbourne Hospital, Journal of Australian Studies, 1984, 14: 3-28; K. S. Inglis, Hospital and Community, A History of the Royal Melbourne Hospital (Melbourne: Melbourne University Press, 1958); Alan Gregory, The Ever Open Door: A History of the Royal Melbourne Hospital (Melbourne: Hyland House, 1998). Judith Godden, Lucy Osburn, a Lady Displaced, Florence Nightingales Envoy to Australia (Sydney: Sydney University Press, 2007); Alison Bashford, Purity and Pollution : Gender, Embodiment and Victorian Medicine (St Martins Press, New York, 1998); Susan M. Reverby, Ordered to Care, The Dilemma of American Nursing, 1850-1945 (Cambridge: Cambridge University Press, 1987); Ann Bradshaw, The Nurse Apprentice, 1860-1977 (Aldershot: Ashgate, 2001); Sioban Nelson, Say Little, Do Much; Nurses, Nuns and Hospitals in the Nineteenth Century (Phila-

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Statistics of the Colony of Queensland, 1900 (Brisbane: Edmond Gregory, Government Printer, 1901), pp. 345-6. Rockhampton, Ipswich, Maryborough, Charters Towers, Toowoomba and Townsville Hospitals all had between 79 and 117 beds.

delphia: University of Pennsylvania Press, 2001); Glenda Strachan, Labour of Love; The History of the Nurses Association in Queensland (St Leonards: Allen and Unwin, 1996). 94 95 96 97 98 Brisbane Hospital By-Laws adopted by the Committee of Management March 28, 1899 (Brisbane, 1899) p. 12. Queensland State Archives, [QSA] Brisbane Hospital Patient Charts 8/1/1900 to 10/5/1900, RSI 3806, Ward 7, R869. Fifty-Third Annual Report of the Brisbane Hospital, 1901 (Brisbane: H. Pole & Co., 1902), p. 13. QSA: Brisbane Hospital Patient Charts 8/1/1900 to 10/5/1900, RSI 3806. These charts form a wonderfully detailed source of information and are referred to repeatedly in what follows. For the routines of care in other hospitals, see: Rosenberg, The Care of Strangers; Guenter Risse, Mending Bodies, Saving Souls; A History of Hospitals (New York: Oxford University Press, 1999); Howell, Technology in the Hospital; Sandra Opdycke, No One Was Turned Away; The Role of Public Hospitals in New York City since 1900 (New York: Oxford University Press, 1999); Lindsay Granshaw and Roy Porter, The Hospital in History (London: Routledge, 1989). For the use of patient records as an historical source, see: Guenter B. Risse and John Harley Warner, Reconstructing clinical activities: patient records in medical history, Social History of Medicine, 1992, 5:183-205; J. H. Warner, The Uses of Patient Records by Historianspatterns, possibilities and perplexities, and J. McCalman, Writing the Womens hospital history with medical records, Health & History, 1999, 1:101-11 & 1:132-8.

99

100 Royal Brisbane Hospital Nursing Archives, Nursing Register, 1898-1901. 101 Ibid; Royal Brisbane Hospital Nursing Archives, Head Nurses monthly diary, 189096 and Nursing Staff Register 1890-94; Helen Gregory and Cecilia Brazil, Bearers of the Tradition: Nurses of the Royal Brisbane Hospital 1888-1993 (Brisbane: Boolarong Publications, 1993); Helen Gregory, A Tradition of Care, A History of Nursing at the Royal Brisbane Hospital (Brisbane: Boolarong Publications, 1988). 102 Joel S. Reiser, The Technologies of Time Measurement: Implications at the Bedside and the Bench, Annals of Internal Medicine, 2000, 132: 31-36; Volker Hess, Standardizing body temperature: quantification in hospitals and daily life, 1850-1900, in Gerard Jorland, Annick Opinel and George Weisz, eds, Body Counts, Medical Quantification in Historical and Sociological Perspectives (Montreal: McGill-Queens University press, 2005), pp. 109-126; M. Sandelowski, Thermometers and Telephones, American Journal of Nursing, 2000, 100: 82-86. For technological assemblages see: David Turnbull, Local Knowledge and Comparative Scientific Traditions, Knowledge and Policy, 1993, 6 (4):29-54; David Wade Chambers & Richard Gillespie, Locality in the History of Science: Colonial Science, Technoscience and Indigenous Knowledge, Osiris, 2000, 15:221-240. 103 QSA: Minute Book of Committee Meetings of Brisbane General Hospital, Minutes of Special Meeting, 16.1.99. 104 Florence Chatfield, Obituary, Ernest Sandford Jackson, Medical Journal of Australia, 1938, II:659-60. 105 QSA: Patient Charts 8.1.1900-10.5.1900, RSI3806. All details of patient care that follow are from this large volume of numbered case records. Each record includes the ward and dates of admission and discharge, and they are bound into the volume by date of discharge. Re-

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cords for Ward 1 were collated from 29 March till the end of the volume, in an attempt to reconstruct patients on the Ward at that date. There may have been some long-term patients discharged after 10 May, who would not have been picked up by this method, but the number probably did not exceed three. Records of seventeen patients were found for 29 March on what was notionally a 20-bed ward. Published patient statistics for the hospital in 1900 report an average daily occupancy of 176 in a 242-bed hospital. Fifty-Second Annual Report of the Brisbane Hospital, 1900 (Brisbane: Alex Muir & Co., 1901), p. 3. 106 QSA: Patient Charts 8.1.1900-10.5.1900, RSI3806, R. 1004. The upper leaden plate was removed on the 8th April and the remaining leaden plate and sutures on the 12th April. The patient was discharged on the 19th April, relieved. 107 QSA: Patient Charts 8.1.1900-10.5.1900, R. 1004. Both Dr Harding and the senior surgeon, Dr Marks, had trained in Ireland. Dr Harding was a Licentiate of the Royal College of Physicians and Surgeons of Ireland and Dr Marks had an MD from Dublin, as well as being a Member (the GP qualification, as opposed to the professional surgeons qualification of Fellow) of the Royal College of Surgeons of England. Roll of Members of Congress, Intercolonial Medical Congress of Australasia, Transactions of the Fifth Session, Brisbane, September 1899 (Brisbane: Government Printer, 1901), pp. 5-7. 108 C. Lawrence, Incommunicable Knowledge; Susan C. Lawrence, Anatomy and Address: Creating Medical Gentlemen in Eighteenth-Century London, in Vivian Nutton and Roy Porter, eds, The History of Medical Education in Britain (Amsterdam: Rodopi, 1995); Roy Porter, William Hunter: a surgeon and a gentleman, in W. F. Bynum and Roy Porter, eds, William Hunter and the Eighteenth-Century Medical World (Cambridge; Cambridge University Press, 1985); M. Jeanne Peterson, Gentlemen and medical men; Sir DArcy Power, The Cultured Surgeon, Australian and New Zealand Journal of Surgery, 1937, 6: 243-247; Terrie M. Romano, Gentlemanly versus Scientific Ideals: John Burdon Sanderson, Medical Education, and the Failure of the Oxford School of Physiology, Bulletin of the History of Medicine, 1997, 71: 224-248; Noel and Jose Parry, The Rise of the Medical Profession, a Study of Collective Social Mobility (London: Croom Helm, 1976). 109 Brisbane Hospital By-Laws, March 28, 1899, p. 2. 110 Fifty-third Annual Report of the Brisbane Hospital, 1901 (Brisbane: H. Pole & Co., 1902). 111 See for, example, the tent ward erected during the erysipelas outbreak of 1882, Ken Inglis, Hospital and Community, A History of the Royal Melbourne Hospital (Melbourne: Melbourne University Press, 1958), illustration opposite p. 54; N Parker, and J. Pearn (eds), Ernest Sandford Jackson, The Life and Times of a Pioneer Australian Surgeon (Brisbane: Australian Medical Association, 1987). 112 Brisbane Hospital By-Laws, March 28, 1899, p. 13. 113 QSA: Patient Charts 8.1.1900-10.5.1900, RSI3806, W10, R945. 114 David Armstrong, A New History of Identity, A Sociology of Medical Knowledge (Basingstoke: Palgrave, 2002) pp119-120. 115 Helen Gregory, Nurse training comes to town, in Brisbane History Group, Brisbane in 1888, the Historical Perspective (Brisbane, 1988), pp.83-95. The Brisbane Hospital only trained female nurses, not wardsmen. 116 Fifty-Third Annual Report of the Brisbane Hospital, 1901 (Brisbane: H. Pole & Co., 1902), p. 9.

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117 Gregory and Brazil, Bearers of the Tradition, pp. 10-11. 118 QSA: Patient Charts 8.1.1900-10.5.1900, RSI3806, W5, R837. 119 Bryan Egan, Ways of a Hospital. St Vincents Hospital Melbourne, 1890s-1990s (St Leonards: Allen and Unwin, 1993); Mary Sheehan with Sonia Jennings, A professions Pathway; Nursing at St Vincents Since 1893 (Melbourne: Arcadia, 2005); Ivo Vellar, The Doers, History of Surgery at St Vincents Hospital, Melbourne 1890s 1950s (Melbourne: Publishing Solutions, 2002); idem, Surgery and surgeons at St Vincents Hospital Melbourne 1950s 2000 (Melbourne: Publishing Solutions, 2004); 120 St Vincents Hospital, Surgical Case Books, Book 1, Mr Syme, p. 5, St Vincents Hospital, Melbourne, Archives. 121 Loose sheet in Book 1, Mr Syme, St Vincents Hospital, Surgical Case Books, Book 1, Mr Syme, p. 165, St Vincents Hospital, Melbourne, Archives. 122 F. E. Hare, The Cold Bath Treatment of Typhoid Fever, the experience of a consecutive series of nineteen hundred and two cases treated at the Brisbane Hospital (London: Macmillan and Co., 1898). A similar treatment had been popular in parts of England a hundred years earlier, but then went out of fashion until revived by Dr Brand of Stettin in 1861: John M. Forrester, The Origins and Fate of James Curries Cold Water Treatment for Fever, Medical History, 2000, 44:57-74. 123 Eugen Hirschfeld, The tepid bath treatment of typhoid fever, Aus Med Gaz, 1900, 19: 22-25. 124 E. S. Jackson, An Address, Medical Journal of Australia, 1926, II: 855-861, p857. Although Galileo invented the first instrument to measure heat and cold, in about 1600, the modern conception of the clinical thermometer and its uses is much more recent technology. Joel S. Reiser, The Technologies of Time Measurement: Implications at the Bedside and the Bench, Annals of Internal Medicine, 2000, 132: 31-36; J. M. S. Pearce, A brief history of the clinical thermometer, QJ Med, 2002, 95: 251-252; M. Sandelowski, Thermometers and Telephones, American Journal of Nursing, 2000, 100(10): 82-86.
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125 QSA, Coroners Court, Record of Depositions Taken and Enquiries During 1890, case no 209. 126 Brisbane Courier, 12 May 1890; Evening Observer, 10 May 1890, p. 4 127 William Harris, Police Magistrate, Report of the Royal Commission appointed to Inquire into and Report upon the Death of Thomas Flynn, in the Brisbane General Hospital, on the 22nd October, 1930 (Brisbane: Government Printer, 1931). 128 Harris, Report of the Royal Commission, p.7. 129 Harris, Report of the Royal Commission, p. 13. 130 Harris, Report of the Royal Commission, p. 11.
Notes for Chapter 4

131 Melbourne Hospital, Report of the Committee of Management, with statement of accounts, list of subscribers and donors and statistical returns, 1902/3-1933/4. 132 Annual Reports, St Vincents Hospital Melbourne, 1893/4-1934/5. 133 The Hornsby and District Hospital Annual report for the Year Ending 30th June 1939, p. 22. 134 Sixty-First Annual Report of the Managers of the Alfred Hospi-

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tal and a List of Subscriptions and Donations, 1931, p.32. 135 Ulrich Trhler, Surgery (modern), in W. F. Bynum and Roy Porter, eds, Companion Encyclopedia of the History of Medicine, volume 2 (London: Routledge, 1997) pp. 984-1007. 136 H. D. Gillies, W. K Fry, H. Wade, Plastic Surgery of the Face: Based on Selected Cases of War Injuries of the Face Including Burns (Frowde: Hodder and Stoughton, 1920); Roger Cooter, Surgery and Society in Peace and War, Orthopaedics and the Organisation of Modern Medicine, 1880-1948 (Basingstoke: Macmillan, 1993).Roger Cooter, The meaning of fractures: orthopaedics and the reform of British hospitals in the inter-war period, Medical History, 1987, 31: 306-332; Thomas Schlich, Trauma surgery and traffic policy in Germany in the 1930s: a case study in the coevolution of modern surgery and society, Bulletin of the History of Medicine, 2006, 80: 73-94; Roger Cooter and Bill Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997). 137 Graeme W. Morgan, A synopsis of radiation oncology in Australia, with particular reference to New South Wales, Australian and New Zealand Journal of Surgery, 1998, 68: 225-235. 138 Kim Pelis, Blood standards and failed fluids: clinic lab, and transfusion solutions in London, 1868-1916, History of Science, 2001, 39:185-211; William H. Schneider, Blood transfusion in Peace and War, 1900-1918, Social History of Medicine, 1997, 10:105-126; idem, Blood Transfusion Between the Wars, Journal of the History of Medicine & Allied Sciences, 2003, 58:105-126; Mark W. Cortiula, Serum and Soluvac: the Australian approach to whole blood transfusion during the Second World War, Journal of the History of Medicine & Allied Sciences, 1999, 54: 413-438; Keith Wailoo, Drawing Blood, Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1999). 139 Patricia Spain Ward, The American reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1981, 36:44-62; J. E. Ross and S. M. Tomkins, The British reception of Salvarsan, Journal of the History of Medicine & Allied Sciences, 1997, 52: 398-423. 140 Dale C. Smith, Appendicitis, appendectomy, and the surgeon, Bulletin of the History of Medicine, 1996, 70: 414-441; Gerald N. Grob, The rise and decline of tonsillectomy in twentiethcentury America, Journal of the History of Medicine and Allied Sciences, 2007, 62: 383-421. 141 Wiebe E. Bijker, Of Bicycles, Bakelites, and Bulbs; Towards a Theory of Sociotechnical Change (Cambridge, Mass.: The MIT Press, 1995); Wiebe E. Bijker, Thomas P. Hughes and Trevor Pinch, eds, The Social Construction of Technological Systems; New Directions in the Sociology and History of Technology (Cambridge, Mass.: The MIT Press, 1987); Wiebe E. Bijker and John Law, eds, Shaping Technology/Building Society; Studies in Sociotechnical Change (Cambridge, Mass.: The MIT Press, 1994). 142 Lawrence D. Longo, The rise and fall of Batteys operation, Bulletin of the History of Medicine, 1979, 53: 244-267; Ornella Moscucci, The Science of Woman, Gynaecology and Gender in England 1800-1929 (Cambridge: Cambridge University Press, 1993); Ann Dally, Women Under the Knife, A History of Surgery (New York: Routledge, 1992); Regina Morantz-Sanchez, Conduct Unbecoming a Woman : Medicine on Trial in Turn-of-the-century Brooklyn (New York: Oxford University Press, 1999); Ludmilla Jordanova, Sexual Visions; Images of Gender in Science and Medicine between the Eighteenth and Twentieth Centuries (Madison: University of Wisconsin Press, 1989). 143 Twentieth Annual Report of the Mater Misericordiae Public Hospital, Brisbane, 1932, pp. 23-27. First Annual report of the Mater Misericordiae Childrens Public Hospital, Brisbane, 1932, pp. 18-20.

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144 QSA, Brisbane Hospital Case Records, 1900, R. 905. 145 Intercolonial Medical Congress of Australasia, 1899, p.p. 210-211. 146 R. A. Stirling, Clinical Lecture, Lecture III, the Treatment of Acute Appendicitis, Intercolonial Medical Journal of Australia, 1898, 3: 437-47; Idem, Surgical Operations at the Melbourne Hospital during the six months from April to October 1897, Intercolonial Medical Journal of Australia, 1898, 3: 17-28. 147 W. B. Vance, A Report of Three Months Abdominal Surgery Performed at the Alfred Hospital, Melbourne by Henry M. OHara, F.R.C.S.I., Senior Surgeon to the Hospital, Intercolonial Medical Journal of Australia, 1898, 3: 86-94. Dr OHara was another past president of the Intercolonial Medical Congress of Australasia. 148 W. J. Long, The Surgical Treatment of Appendicitis, Intercolonial Medical Journal of Australia, 1898, 3: 609-11 149 Smith, Appendicitis. Many surgeons have written about the significance of this operation. See, for example, P. Mirilas & J E Skandalakis, Not just an appendix: Sir Frederick Treves, Archives of Diseases of Childhood, 2003, 88: 549-553. 150 For the Brisbane response to this high profile surgery see Brisbane Courier Wednesday 25 June 1902, p. 5; Thursday 26 June 1902, passim. The Courier sought the advice of several of Brisbanes leading surgeons, none of whom were named, and all of whom warned the public that it might be quite some time before it became clear whether or not the King would survive. 151 Intercolonial Medical Congress of Australasia, 1899, p. 23. 152 T. Farranridge, Drainage, Australian & New Zealand Journal of Surgery, 1933, 3: 184-191, p. 187. 153 Ulrich Trhler, To operate or not to operate? Scientific and extraneous factors in therapeutical controversies within the Swiss Society of Surgery 1913-1988, Clio Medica, 1991, 22: 89-113. 154 Christopher Heath, ed., Dictionary of Practical Surgery by Various British Hospital Surgeons (London: Smith, Elder & Co., 1886) vol II, p.644. 155 Frederick Treves, ed., A Manual of Surgery in treatises by various authors in three volumes (London: Cassell & Company, 1888) vol III, p. 79. 156 Albert Carless, Manual of Surgery (Rose and Carless) for students and practitioners, tenth edition (London: Bailliere, Tindall and Cox, 1921), pp. 933-937. 157 Carless, Manual of Surgery, p. 967. 158 Quoted in Gladstone R. Osborn and Noel Roydhouse, The Tonsillitis Habit (Christchurch NZ: W. P. Roydhouse, 1976), p. 1. 159 JA Glover, The incidence of tonsillectomy among children, Proceedings of the Royal Society of Medicine, 1938; 160 Klim McPherson, Commentary: James Alison Glover (1874-1963), OBE, CBE, MD, DPH,FRCP: health care variations research then and now, International Journal of Epidemiology, 2008: 1-4; 161 JA Glover, The paediatric approach to tonsillectomy, Archives of Diseases of Childhood, 1948, 23: 1-6; JW Miller, WS Walton and EG Cox, Growing up in Newcastle-upon-Tyne (Lon-

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don, 1960); Alan M. Gittelsohn and John E. Wennberg, On the incidence of tonsillectomy and other common surgical procedures, in John P. Bunker, Benjamin A. Barnes and Frederick Mosteller, eds, Costs, Risks and Benefits of Surgery (New York: Oxford University Press, 1977), pp. 91-106; Marilyn I Rob, Ear nose and throat surgery among young Australian children, (unpublished PhD thesis, University of New South Wales, 2005). 162 Gerald N. Grob, The rise and decline of tonsillectomy in twentieth-century America, Journal of the History of Medicine and Allied Sciences, 2007, 62(4): 383-421, pp. 401 & 407. 163 James A. Glover, The paediatric approach to tonsillectomy. 164 Gladstone R Osborn & Noel Roydhouse, The Tonsillitis Habit (W. P. Roydhouse: Christchurch, 1976). 165 Osborn & Roydhouse, The Tonsillitis Habit, p. v. 166 Michael Bloor, Bishop Berkeley and the adenotonsillectomy enigma: an exploration of variation in the social construction of medical disposals, Sociology, 1976, 10: 43-61, p. 59. 167 Catherine Pope, Contingency in everyday surgical work, Sociology of Health & Illness, 2002, 24: 369-384. 168 M. Burton, Tonsillectomy, Archives of Diseases of Childhood, 2003, 88: 95-96, p. 96. 169 Grob, The rise and decline of tonsillectomy; EH Van Den Akker, AW Hoes, MJ Burton & AGM Schilder, Large international differences in adenotonsillectomy rates, Clinical Otolaryngology, 2004, 29: 161-164; Burton, Tonsillectomy, Archives of Diseases of Childhood, 2003, 88: 95-96; 170 Geoffrey Kaye, Observations on anaesthesia in cerebral surgery, Australian & New Zealand Journal of Surgery, 1937, 7: 134-162. 171 Leonard C. Lindon, The cerebro-spinal fluid in relation to neuro-surgery, Australian & New Zealand Journal of Surgery, 1937, 7: 20-39. 172 Gilbert Phillips, A new method of head-fixation for operations in the sitting position, Australian & New Zealand Journal of Surgery,1937, 7:67-69. 173 Sandra W. Moss, Floating kidneys: a century of nephroptosis and nephropexy, Journal of Urology, 1997, 158: 699-702; Benjamin A. Barnes, Discarded operations: surgical innovation by trial and error, in Bunker, Barnes and Mosteller, eds, Costs, Risks and Benefits of Surgery, pp. 109-123. 174 Annmarie Adams and Thomas Schlich, Design for Control: Surgery, Science and Space at the Royal Victoria Hospital, Montreal, 1893-1956, Medical History, 2006, 50:303-324, p. 304. See also Schlich, Surgery, Science and Modernity: operating rooms and laboratories as spaces of control, History of Science, 2007, 45: 231-256; idem: Surgery, Science and Industry, a Revolution in Fracture Care, 1950s-1990s (Palgrave Macmillan, Basingstoke, 2002).
Notes for Chapter 5

175 Pierre Bourdieu, Distinction, A Social Critique of the Judgment of Taste, trans. Richard Nice (London: Routledge, 1984), (1st pub. Paris, 1979); see also idem, The Field of Cultural Production (Cambridge: Polity Press, 1993); George Weisz, Divide and Conquer, a Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006). Wilde, Practising Surgery. 176 N. Rasmussen, The moral economy of the drug company-medical scientist collaboration in

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interwar America, Social Studies of Science, 2004, 34:161-85; E. R. Brown, Rockefeller Medicine Men, Medicine and Capitalism in America (Berkeley, University of California Press, 1979); Bynum, Science and the Practice of Medicine; Warner, The History of Science and the Sciences of Medicine; for the importance of trust more broadly see: J. G. Bruhn, Trust and the Health of Organizations (New York: Kluwer Academic, 2001); E. L. Khalil, ed., Trust (Cheltenham: Edward Elgar, 2003); F. Fukuyama, Trust, The Social Virtues and the Creation of Prosperity (London: Penguin, 1995). 177 H. M. Marks, The Progress of Experiment, Science and Therapeutic Reform in the United States, 1900-1990 (Cambridge: CUP, 1997). 178 A. L. Cochrane, Effectiveness and Efficiency: random reflections on health services (London: Nuffield Provincial Hospitals Trust, 1972); K. F. King, The Natural History of Orthopaedic Enthusiasms, Australia and New Zealand Journal of Surgery [A&NZJS] 1993, 63:429-34; M. L. Meldrum, A Brief History of the Randomized Controlled Trial: from oranges and lemons to the gold standard, Hematology/Oncology Clinics of North America, 2000, 14:745-60; J. P. Royal, A History of Sympathectomy, A&NZJS, 1999, 69:302-7; R. G. Springall, Cholecystectomy: ironmasters and eggheads, Journal of the Royal Society of Medicine, 1988, 81:560-63. 179 Medical Marvel, University of Queensland Graduate Contact, 2004, 30: 30. 180 E. Freidson, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970); idem, Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970); E. Willis, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989). 181 E. P. Thompson, The moral economy of the English crowd in the eighteenth century, Past and Present, 1971, 50:76-136. 182 J. Le Grand, From Knight to Knave? Public Policy and Market Incentives, pp. 21-30, and B. S. Frey, Motivation and Human Behaviour, pp. 31-50, both in: P. Taylor-Gooby, ed., Risk, Trust and Welfare (Basingstoke: Macmillan Press, 2000); Adam Smith, The theory of moral sentiments (London: A. Millar, 1759). 183 Adam Smith, An inquiry into the nature and causes of the wealth of nations, 2 vols, (London, 1776); Eliot Freidson, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970); idem, Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970); Evan Willis, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989). 184 J. Gillespie, The Price of Health: Australian Governments and Medical Politics 1910-1960 (Melbourne: Cambridge University Press, 1991); D. Green & L. Cromwell, Mutual Aid or Welfare State, Australias Friendly Societies (Sydney: George Allen & Unwin, 1984); J. S. Deeble, and R. B. Scotton, Health Care Under Voluntary Insurance: Report of a Survey (Melbourne: University of Melbourne, 1968); Sidney Sax, A Strife of Interests. Politics and Policies in Australian health services (Sydney: George Allen and Unwin, 1984); S. J. Duckett, Structural Interests and Australian Health Policy, Social Science and Medicine, 1984, 18: 959-66; D. Mackay, Politics of reaction: the Australian Medical Association as a pressure group, in H. Gardner, ed., The Politics of Health; the Australian experience (Melbourne: Churchill Livingstone, 1989), pp. 293-297; R. B. Scotton, Milestones on the road to Medibank and Medicare, MJA, 2000, 173:5-7. 185 J. Rogers Hollingsworth, A Political Economy of Medicine: Great Britain and the Unit-

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ed States (Baltimore: Johns Hopkins University Press, 1986); F. Honigsbaum, Health, Happiness, and Security, The creation of the National Health Service (London: Routledge, 1989); C. D. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Montreal: McGill-Queens University Press, 1986). 186 Aus Med Gaz, 1895, 14: 118. 187 Letter of Dr. Billy Little, Feb. 16, 1890, Warracknabeal, in: Margaret Gillett, Dear Grace, A Romance of History (Melbourne: Melbourne University Press, 1986), p.89. 188 Ibid, April 10th 1890, p. 96. Doctoring was a word for the behaviour of patients who went from one doctor to another, trying to find a cure for an intractable condition. Dr Little expressed all prices in his letters in Canadian dollars. 189 Robert H. Ritchie, Some cases of hydatid disease, Intercolonial Medical Journal of Australasia, 1898, 3: 604-608. 190 Edward Ryan, Early medical practice in north-western Victoria, in Department of Medical History, University of Melbourne, ed., Papers Presented at a Seminar on the History of Medicine, 13-15 April 196, (Sydney: Australasian Medical Publishing Co., 1968), pp. 64-77. 191 H. M. Collins, The TEA Set: tacit Knowledge and Scientific Networks, Science Studies, 1974, 4: 165-86. 192 Wilde, See one, do one; Schlich, Surgery, Science and Industry; Andrew Warwick, Xrays as Evidence in German Orthopaedic Surgery, 1895-1900, Isis, 2005, 96, 1-24. 193 Owen H. Wangensteen, Surgery and Surgical Travel Groups, Surgery Gynecology & Obstetrics, 1978, 147: 246-254; Peter Boreham, Surgical Journeys, A History of the Surgical Union which became the 1921 Surgical Travelling Club of Great Britain (Devon: Merlin Books, 1990); Wangensteen, Surgery and Surgical Travel Groups, p. 253; Rutherford Morison, Lord Moynihan, a Personal Appreciation, British Journal of Surgery, 1936, 24: 4-6; Sir Berkeley G. A. Moynihan, The Ritual of a Surgical Operation, British Journal of Surgery, 1920, 8: 27-35. 194 Mario Biagioli, Tacit Knowledge, Courtliness, and the Scientists Body, in Choreographing History, Susan Leigh Foster, ed., (Bloomington: Indiana University Press, 1995), 69-81, p. 71; Michael Polanyi, Personal Knowledge (London: Routledge & Kegan Paul, 1958), p. 53; idem, The Tacit Dimension (New York: Anchor Books, 1967).1 195 David Turnbull, Masons, Tricksters and Cartographers, Comparative Studies in the Sociology of Scientific and Indigenous Knowledge (Harwood Academic Publishers, 2000), p. 42. 196 Lesley M. Williams, No Easy Path, The life and times of Lillian Violet Cooper MD, FRACS (1861-1947) Australias first woman surgeon, (Brisbane: Amphion Press, 1991). 197 Sandy Callister, Broken gargoyles: the photographic representation of severely wounded New Zealand soldiers, Social History of Medicine, 2007, 20: 111-130; A. Bamji, Sir Harold Gillies: surgical pioneer, Trauma, 2006, 8: 143-156; Joanna Bourke, The battle of the limbs: amputation, artificial limbs and the Great War in Australia, Australian Historical Studies, 1998, 110: 49-67; 198 Christopher Lawrence, Medicine in the Making of Modern Britain, 1700-1920 (London: Routledge, 1994), p. 78. 199 Ivo Vellar, The Doers, History of Surgery at St Vincents Hospital Melbourne 1890s-1950s (Melbourne: Publishing Solutions, 2002), p.11.

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200 F. Gordon Bell, The George Adlington Syme Oration, on hospital problems and surgical education, Australian & New Zealand Journal of Surgery, 1933, 3: 3-23, p.2. 201 Anon, Robert Hamilton Russell, Australian & New Zealand Journal of Surgery, 1933, 3: 110-112, p. 112. 202 H. H. Schlink, Royal Prince Alfred Hospital: its history and surgical development, Australian & New Zealand Journal of Surgery, 1933, 3: 115-129, p.122. 203 Douglas Miller, Sir Alexander MacCormick: Man and surgeon, Australian & New Zealand Journal of Surgery, 1969, 38: 189-195, 193. 204 Stirling, p. 163. 205 Alexander Francis, Then and Now, The Story of a Queenslander (London: Chapman and Hall, 1935), pp. 123-4. 206 Miller, A Surgeons Story, p. 118. 207 Miller, A Surgeons Story, p. 53. 208 Vellar does mention his work as a visiting surgeon at private clinics overseas, such as the Mayo: I vo D. Vellar, Hugh Berchmans Devine: Surgical Visionary and Great Australian, Australian and New Zealand Journal of Surgery, 2000, 70: 801-812. Vellar also mentions Devines private consulting rooms. 209 For example: Melbourne Hospital, Eighty-fifth Annual Report of the Committee of Management with Statement of Accounts, Lists of Subscribers and Donors and Statistical Returns, 1932. 210 Mater Misericordiae Childrens Public Hospital Brisbane, First Annual Report, 6th July, 1931 to 30th June, 1932, (Brisbane: Sisters of Mercy, 1932), p. 1. 211 Mater Misericordiae Public Hospitals Brisbane, Twentieth Annual Report, 1st July, 1931 to 30th June, 1932, (Brisbane: Sisters of Mercy, 1932), p. 13. 212 See, for example, the 1933 entry for Julian Ormond Smith: M.D., B.S., Melb.; F.R.C.S., Eng. Resident Medical Officer, 1st Sept., 1926. Registrar, 1st November 1927, to 31st August 1928. Out-patient Surgeon, 25th March, 1930. Melbourne Hospital, Eighty-sixth Annual Report of the Committee of Management with Statement of Accounts, Lists of Subscribers and Donors and Statistical Returns, (Melbourne: Spectator Publishing Co. Pty. Ltd.,1933), p.10. 213 The Deluge, Speculum, 1932, 130: 54. 214 Herald, 17 February 1932. 215 Reiger, The Disenchantment of the Home. 216 Canberra Times, 2 April 1928. 217 Smith, The History of the Royal Australasian College of Surgeons from 1920 to 1935, 27. 218 Australasian, 6 March 1935.
Notes for Chapter 6

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219 Sally Wilde and Geoffrey Hirst, Learning from mistakes: early twentieth century surgical practice, Journal of the History of Medicine & Allied Sciences, 2009, 64(1): 38-77

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220 Archibald Watson, Diaries, Series 64, Archives of the Royal Australasian College of Surgeons, Melbourne. 221 Jennifer M T Carter, Painting the Islands Vermillion; Archibald Watson and the Brig Carl (Melbourne: Melbourne University Press, 1999); R G Elmslie, Mrs-L case a celebrated South Australian surgical case, Australian and New Zealand Journal of Surgery, 1991, 61:780-788; J Estcourt Hughes, A History of the Royal Adelaide Hospital (Adelaide: Board of Management of the Royal Adelaide Hospital, 1967). 222 In all quotations, round bracket, (), are in the original text, whilst square brackets, [], enclose my interpolations. 223 Watson, Series 64, P1/2/30, Monday November 10th 1919. 224 Charles L. Bosk, Forgive and Remember; Managing Medical Failure (Chicago: University of Chicago Press, 1979), especially chapter four. 225 R. Hamilton Russell, The etiology and treatment of inguinal hernia in the young, The Lancet, 1899, 154: 1353-1358, reprinted in idem, Papers & Addresses in Surgery, selected and revised (Melbourne: Allan Grant, 1923), p. 41. 226 For instance, Watson noted a new method for chromicising catgut during a visit to Sydney in March 1910. Watson, Series 64, P1/2/21. See also Albert Carless, Manual of Surgery (London: Bailliere, Tindall and Cox, tenth edition 1921), instructions for purifying ligatures and sutures p. 289. 227 Newland The Archibald Watson Memorial Lecture, p. 384. 228 Watson, Series 64, P1/2/21, Thursday January 20th 1910. 229 There is now an enormous body of work on this topic, much of it following the leads provided by the Harvard Medical Practice Study: T A Brennan, L L Leape, N M Laird, et al. Incidence of adverse events and negligence in hospitalized patients: Results from the Harvard Medical Practice Study I, New England J. Med, 1991, 324:370-376; L L Leape, T A Brennan, N M Laird, et al. The nature of adverse events in hospitalized patients: Results from the Harvard Medical Practice Study II, New England J. Med, 1991, 324:377-384. 230 Jeffrey A Koempel, On the origin of tonsillectomy and the dissection method, Laryngoscope, 2002, 112:1583-1586; J A Koempel, C A Solares, P J Koltai, The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleepdisordered breathing in children, Journal of Laryngology & Otology, 2006:1-8. 231 See above, chapter 4. 232 Watson, Series 64, P1/2/10. 233 Watson, Series 64, P1/2/10, Friday 2 June 1899. 234 Justine Randers-Pehrson, The Surgeons Glove (Springfield, Illinois: Charles C Thomas, 1960); Joseph M. Miller, William Halsted and the use of the surgical rubber glove, Surgery, 1982, 92: 541-543; Barbara Rawlings, Coming clean: the symbolic use of clinical hygiene in a hospital sterilising unit, Sociology of Health and Illness, 1989, 11: 279-293; S. J. C. Mills, D. J. Holland, and A. E. Hardy, Operative field contamination by the sweating surgeon, Australian and New Zealand Journal of Surgery, 2000, 70: 837-39; Christopher Poon, David J. Morgan, Franklin Pond, John Kane, and Bruce R. Tulloh, Studies of the surgical scrub,

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Australian and New Zealand Journal of Surgery, 1998, 68: 65-67. On ritual see especially: Sir Berkeley G. A. Moynihan, The Ritual of a Surgical Operation, British Journal of Surgery, 1920, 8: 27-35; see also: Pearl Katz, Ritual in the Operating Room, Ethnology, 1981, 20: 335-50; H. M. Collins, Dissecting Surgery: Forms of Life Depersonalized, Social Studies of Science, 1994, 24: 311-33; Stefan Hirschauer, The Manufacture of Bodies in Surgery, Social Studies of Science, 1991, 21: 279-319; idem, Towards a Methodology of Investigations into the Strangeness of Ones Own Culture: A Response to Collins, Social Studies of Science, 1994, 24: 335-46; Nicholas J. Fox, Fabricating Surgery: A Response to Collins, Social Studies of Science, 1994, 24: 347-54; idem, Space, Sterility and Surgery: Circuits of Hygiene in the Operating Theatre, Social Science and Medicine, 1997, 45: 649-657. 235 Sir Victor Hurley, The development and practice of surgery in Australia during fifty years, Medical Journal of Australia, 1951, I: 5-10, p. 5. 236 Watson, Series 64, P1/2/5. 237 Watson, Series 64, P1/2/21, 20 January 1910. 238 Watson, Series 64, P1/2/13, 4 September 1902. 239 On this point, see also Bosk, Forgive and Remember. 240 M S S Earlam and J W S Laidley, The surgical diaries of M S S Earlam and J W S Laidley, 1936-7, 1938 and 1948, Archives of the Urological Society of Australasia, held in the Archives of the Royal Australasian College of Surgeons, Melbourne, Earlam, 30 Nov. 1936. 241 M S S Earlam and J W S Laidley, Surgical diaries, Laidley, 4 May 1938. 242 Ibid., Laidley, 15 May 1938. 243 Ibid., Earlam, 25 November 1936.
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244 Ibid., Earlam, 2 November 1936. 245 Ibid., Laidley, 21 March 1938. 246 Ibid., Laidley, 21 March 1938.
Notes for Chapter 7

247 RACS Archives Melbourne: Minutes and Council Papers, Se 7, 16 February 1932, p. 32. 248 Loyal Davis, Fellowship of Surgeons - A history of the American College of Surgeons (Springfield: Charles C. Thomas, 1966); Kenneth M. Ludmerer, Time to Heal, American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999); Peter D. Olch, Evarts A. Graham, The American College of Surgeons, and the American Board of Surgery, Journal of the History of Medicine & Allied Sciences, 1972, 27: 247-261; Mark M. Ravitch, A Century of Surgery, The History of the American Surgical Association 1880-1980 (Philadelphia: J. B. Lippincott Company, 1981); J. Stewart Rodman, History of the American Board of Surgery 1937-1952 (Philadelphia: J. B. Lippincott Company, 1956); Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971). 249 Colin Smith, The Shaping of the RACS 1920-1960, in David E. Theile, P. H. Carter, and C. V. Smith, eds, Royal Australasian College of Surgeons, Handbook (Melbourne: RACS, 1995), 13-54; Julian Smith, The History of the Royal Australasian College of Surgeons from 1920 to 1935. See also: Wyn

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Beasley, The Mantle of Surgery, The First Seventy-Five Years of the Royal Australasian College of Surgeons. 250 Sir George A. Syme, The Aims and Objects of the College of Surgeons of Australasia, Medical Journal of Australia, 1928, I: 488-491. 251 Syme, The Aims and Objects, p. 491. 252 Hamilton Russell, The Royal College of Surgeons of England, Journal of the College of Surgeons of Australasia, 1928, 1: 4-9. 253 C. Smith, The Shaping of the RACS; J. Smith, History of the Royal Australasian College of Surgeons. 254 Quoted by Devine: RACS Archives Melbourne: Sir Hugh Berchmans Devine, SB 28/7, Memoirs. 255 Rosemary Stevens, Medical Practice in Modern England and the Impact of Specialization and State Medicine (New Haven: Yale University Press, 1966). 256 Old Boys Column, The Speculum, 1932, 129: 66-67. 257 Ibid. 258 Quoted in J. Stewart Rodman, History of the American Board of Surgery 1937-1952 (Philadelphia: J. B. Lippincott Company, 1956), p.1; The address was published in the Annals of Surgery in October 1935. 259 James Elliott, The Complete Surgeon, Australian and New Zealand Journal of Surgery, 1937, 7: 177-180, 177. 260 Lord Moynihan was something of an exception. Although he emphasised the other attributes of his conception of an ideal surgeon, he devoted much attention to description of the wonderful craft of surgery: Sir Berkeley G. A. Moynihan, The Ritual of a Surgical Operation, British Journal of Surgery, 1920, 8: 27-35.
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261 R. B. Wade, Surgical training, Australian and New Zealand Journal of Surgery, 1934, 3. 262 Syme, The Aims and Objects, p. 490. 263 Ibid. 264 A. W. Beasley, The Mantle of Surgery, The First Seventy-Five Years of the Royal Australasian College of Surgeons (Melbourne: RACS, 2002); The College of Surgeons of Australasia (which includes New Zealand) By-Laws (Dunedin: College of Surgeons of Australasia, 1927); Douglas Miller, The History of the Royal Australasian College of Surgeons from 1935 to 1960, Australian and New Zealand Journal of Surgery, 1972, 41: 302-311; Colin Smith, The Shaping of the RACS 1920-1960, in David E. Theile, P. H. Carter, and C. V. Smith, eds, Royal Australasian College of Surgeons, Handbook (Melbourne: RACS, 1995), 13-54; Julian Ormond Smith, The History of the Royal Australasian College of Surgeons from 1920 to 1935 (Melbourne: RACS, 1970). 265 See, for example: H. W. Armit, A Matter of Ethics, Medical Journal of Australia, 1921, I:443. 266 E. Freidson, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970); idem, Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970); E. Willis, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989). 267 Andrew Morrice, The Medical Pundits: Doctors and Indirect Advertis-

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ing in the Lay Press, 1922-1927, Medical History, 1994, 38:255-80. 268 Bryan Egan, Specialization, Surgery and the Sydney Bulletin, Australian and New Zealand Journal of Surgery, 1988, 58: 983-987; T. S. Pensabene, The Rise of the Medical Practitioner in Victoria (Canberra: Australian National University, 1980); Evan Willis, Medical Dominance, The division of labour in Australian health care (Sydney: Allen & Unwin, 1989); See also James A. Gillespie, The Price of Health: Australian Governments and Medical Politics 1910-1960 (Melbourne: Cambridge University Press, 1991). 269 Egan, Specialization and the Sydney Bulletin. 270 Evening Post, 6 April 1933; the Age, 1 March 1934; New Zealand Herald, 19 January 1937. 271 A survey of the Herald, the Sun and the Age revealed items in each paper every day between 16 and 20 February 1932. Not one piece was even remotely critical. 272 Royal Australasian College of Surgeons, Proceedings of the Annual Meeting, Australian and New Zealand Journal of Surgery, 1932, 1: 443-448. 273 RACS Archives Melbourne: Sir Hugh Berchmans Devine, SB 28/7, Memoirs. 274 Victor W. Turner, The Ritual Process (London: Routledge & Kegan Paul, 1969); R. Strong, Splendour at Court: Renaissance Spectacle and Illusion (London, Weidenfield and Nicolson, 1973). This study also draws on ideas from: E. J. Hobsbawm and T. Ranger, The Invention of Tradition (Cambridge: Cambridge University Press, 1983); David Cannadine, Splendor out of Court: Royal Spectacle and Pageantry in Modern Britain, c. 1820-1977, in Sean Wilentz, ed., Rites of Power: Symbolism, Ritual and Politics Since the Middle Ages (Philadelphia: University of Philadelphia Press, 1985). 275 Pensabene has shown the importance of newspapers in both reflecting and helping form public perceptions of doctors. Pensabene, The Rise of the Medical Practitioner in Victoria. This section is based on the press cuttings held in the Archives of the Royal Australasian College of Surgeons: RACS Archives Melbourne: Press Cuttings, Se 216, 1926-. The cuttings are mainly from metropolitan newspapers in Melbourne, Sydney and Auckland. There are a limited number of cuttings from Adelaide, Hobart and Launceston, and the coverage of New Zealand is not limited to Auckland. Western Australia, Queensland and rural Australia are not represented. The cuttings are pasted into a book in date order. While by no means comprehensive, there is no reason to doubt that the cuttings are broadly representative of metropolitan press reporting of the College in its early years. 276 Cannadine, Splendor out of Court, p. 223. 277 Cannadine, Splendor out of Court, p. 224. 278 RACS Archives Melbourne: Sir Alan Newton, SB 44/18, Alan Newton, A personal tribute. 279 The Sun 16 March 1939; Webb-Johnson also presented a Rudyard Kipling manuscript to Australia, handing it over to Mr Lyons at a ceremony in Canberra. Argus, 19 March 1939. 280 Peter G. Jones, The Arms of the Colleges of Surgeons I: The Arms and Mace of the Royal Australasian College of Surgeons, Australian and New Zealand Journal of Surgery 40 (1970): 105-110. The Mace was a gift from the Members of Council of the Royal College of Surgeons of England, and made by London silversmith Omar Ramsden in silver gilt. The grant of the prefix Royal came when the mace was nearly finished, and

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Royal was therefore added in front of College of Surgeons of Australasia. 281 Beasley, The Mantle of Surgery; C. Smith, The Shaping of the RACS; J.Smith, The History of the Royal Australasian College of Surgeons. 282 Sir Henry Simpson Newland, Presidents Address, Australian and New Zealand Journal of Surgery 1 (1931): 3-5. 283 The original plan was that Moynihan would present the mace, but his wife was taken ill and Fagge travelled to Australia to present it in his stead. Daily Guardian, Sydney, 6 January 1931. 284 C H Fagge presented the mace instead of Lord Moynihan. Fagge is reported as saying: And now companion of my waking thoughts for many months, farewell. You have I watched from earliest hours when, a plate of virgin silver, you gave yourself to be fashioned by the craftsmans skill. Your every spray of wattle, every frond of fern, have come to life within my ken, and gradually, once a thing inanimate, your spirit has entwined itself around mine. Today we part, but it is my hope that your new friends will ever hold you in their hearts, not only as a kingly emblem, richly wrought, but as a spirit of affection which has passed from Mother Country to her sons. College of Surgeons, Brilliant ceremony, Great Mace presented, The Argus, Thursday 18 February 1932, 7. 285 RACS Archives Melbourne: Colin Smith, Se 31/1273, The ceremonial traditions and symbols of the College, (1996). 286 Quoted in Bosk, Forgive and Remember; preface to 2nd edition, 2003, p. xvi. 287 Sally Wilde, Surgical Theatre, Gifted Performance: The moral economy of surgical training, in Christy Collis and Maggie Nolan, eds, Benevolence, Journal of Australian Studies 85 (Perth: API Network, Australia Research Institute, 2005) 27-36; 194-8. 288 Syme, The aims and objects, p. 491.
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289 Sir Berkeley G. A. Moynihan, The Ritual of a Surgical Operation, British Journal of Surgery, 1920, 8:27-35.

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